
S88& 



LIBRARY OF CONGRESS. 

~VR p- a. c 
Chap._Ll.l Copyright No. 

ShelfJBclS 



UNITED STATES OF AMERICA. 



A TEXT-BOOK 



OF 



DISEASES OF THE 



NOSE AND THROAT 



BY 

FRANCKE HUNTINGTON BOSWORTH, 

A. B. Cantab., A.M., M.D. 

PROFESSOR OP DISEASES OP THROAT IN BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK; CONSULT- 
ING LARYNGOLOGIST TO THE PRESBYTERIAN AND ST. VINCENT HOSPITALS, NEW YORK; HONO- 
RARY FELLOW OF THE BRITISH OTOLOGICAL, LARYNGOLOGICAL, AND RHINOLOGICAL 
ASSOCIATION ; CORRESPONDING MEMBER OF THE SOCIETE FRANCAISE d'OTOLOGIE 
ET DE LARYNGOLOGIE J FELLOW OF THE AMERICAN LARYNGOLOGICAL 
ASSOCIATION, THE ACADEMY OF MEDICINE. NEW YORK ; MEMBER 
OF THE MEDICAL SOCIETY OF NEW YORK STATE, AND OP 
THE COUNTY SOCIETY OF NEW YORK, ETC. 



ILLUSTRATED WITH ONE HUNDRED AND EIGHTY- SIX ENGRAVINGS 



NEW YORK ^° 

WILLIAM WOOD AND COMPANY 

1896 






Copyright by 
WILLIAM WOOD & COMPANY 



PRESS OF 

THE PUBLISHERS' PRINTING COMPANY 

132-136 W. FOURTEENTH ST. 

NEW YORK. 



PREFACE. 



My recent work ou the Nose and Throat in two volumes having 
been considered somewhat too voluminous for the use of students, it 
has been thought best to prepare the following volume, designed es- 
pecially for the use of the general practitioner and student. 

The work is mainly a condensation of my former two volumes into 
one, in which the effort has been to retain all that is of practical use 
so far as possible. This has been accomplished by eliminating those 
parts of the work which were of value only for reference, and I trust 
that it has been done to the satisfaction of the reader. Some new 
material has been added and some few changes made, but in essen- 
tials the single volume is the same as the larger edition. The work 
of reduction has been done by my friend, Dr. Aimee Raymond 
Schroeder, without whose valuable assistance this publication would 
scarcely have been feasible. 

F. H. B. 

26 West Forty-Sixth Street, 
August. 1896. 



CONTENTS. 



SECTION I. 

Diseases of the Nasal Passages. 
CHAPTER I. 

PAGE 

Methods of Examining the Upper Air Passages, 3-16 

The Laryngoscope, 4-6 

The Fixed Apparatus, 6 

The Examination, 6-8 

Rhinoscopy, 8-15 

The Rhinoscopic Image, 15-16 

CHAPTER II. 

Methods of Treating the Upper Air Passages by Means of Instruments, . 17-24 

Insufflations, 17-18 

Douches, 18-19 

Atomizers, 19-22 

Inhalations, 22-24 

CHAPTER III. 

Mucous Membranes, 25-31 

Anatomy, 25-26 

Physiology, 26 

Inflammation of Mucous Membranes, 26-31 

CHAPTER IV. 

Taking Cold 32-40 

CHAPTER V. 

The Anatomy of the Nose, 41-47 

The External Nose, 41 

The Nasal Fossae, 41-43 

The Accessory Sinuses, 43-44 

The Mucous Membrane, 44-46 

The Turbinated Bodies, ■ . 46-47 

CHAPTER VI. 

The Physiology of the Nose, 48-53 

The Sense of Smell, 48-49 

The Function of the Nose in Phouation, 49 

The Function of the Nose in Respiration, 49-53 



vi CONTENTS. 

CHAPTER VII. 

PAGK 

General Considerations concerning Catarrhal Diseases, .... 54-58 

CHAPTEE VIII. 
Acute Rhinitis, 59-67 

CHAPTER IX. 
Hypertrophic Rhinitis, 68-88 

CHAPTER X. 
Purulent Rhinitis of Children, 89-94 

CHAPTER XI. 
Atrophic Rhinitis, 95-104 

CHAPTER XII. 
Croupous or Fibrinous Rhinitis, 105-108 

CHAPTER XIII. 
Nasal Reflexes, 109-114 

CHAPTER XIV. 
Hay Fever, or Vaso-Motor Rhinitis, 115-132 

CHAPTER XV. 
Asthma, or Vaso-Motor Bronchitis, 133-144 

CHAPTER XVI. 
Nasal Hydrorrhoea, 145-151 

CHAPTER XVII. 
Anosmia, 152-156 

CHAPTER XVIII. 

Deformities of the Nasal Septum, 157-173 

Dislocation of the Columnar Cartilage, 170 

Perforation of the Septum, 171-172 

Abscess of the Septum, 172-173 

CHAPTER XIX. 
Epistaxis, 174-180 

CHAPTER XX. 
Foreign Bodies in the Nasal Passages, 181-183 

CHAPTER XXI. 
Rhinoliths, 184-185 

CHAPTER XXII. 
Parasites in the Nasal Cavities, . . > . . * . • 186-187 



CONTEXTS. VI] 

CHAPTER XXIII. 

PAGE 

Syphilis pf the Nasal Passages, 188-200 

The Primary Lesion, 188-189 

The Syphilitic Coryza or Erythema, 189 

The Mucous Patch, 189 

The Superficial Ulcer, 189-190 

The Gummy Tumor, 190-193 

The Deep Ulcer of Syphilis, and Bony Necrosis, .... 193-197 

Treatment, 197-200 

CHAPTER XXIV. 
Congenital Syphilis of the Nasal Passages, 201-204 

CHAPTER XXV. 
Tuberculosis of the Nasal Passages, 205-207 

CHAPTER XXVI. 
Lupus of the Nasal Passages, 208-211 

CHAPTER XXVII. 
Rhino-scleroma, 212-215 

CHAPTER XXVIII. 
Nasal Polypus, or Myxoma, 216-225 

CHAPTER XXIX. 
Fibroma of the Nasal Passages, 226-230 

CHAPTER XXX. 
Osteoma of the Nasal Passages, 231-233 

CHAPTER XXXI. 
Papilloma of the Nasal Passages, 234-236 

CHAPTER XXXII. 
Adenoma of the Nasal Passages, 237 

CHAPTER XXXIII. 
Cystoma of the Nasal Passages, 238 

CHAPTER XXXIV. 

%- Angioma of the Nasal Passages, 239-241 

CHAPTER XXXV. 
Chondroma of the Nasal Passages, 242 

CHAPTER XXXVI. 
Sarcoma of the Nasal Passages, 243-246 



Till 



CONTENTS. 



CHAPTER XXXVII. 
Carcinoma of the Nasal Passages, 



CHAPTER XXXVIII. 

Diseases of the Accessory Sinuses of the Nose, 
Disease of the Antruip, 
Diseases of the Ethmoidal Sinuses, 
Diseases of the Sphenoidal Sinuses, . 
Disease of the Frontal Sinuses, . 
Differential Diagnosis between Diseases of the Accessory Cavities, . 274-275 





PAGE 


, 247-249 


. 250 


-275 


. 250-261 


. 261 


-267 


. 267- 


-271 


. 271- 


-274 



SECTION II. 

Diseases of the Naso-Pharynx. 

CHAPTER XXXIX. 

PAGE 

The Anatomy and Physiology of the Naso-Pharynx, .... 279-283 

Anatomy of the Naso-Pharynx, 279-282 

Physiology of the Naso-Pharynx, 283 

CHAPTER XL. 
Acute Naso-Pharyngitis, 284-287 

CHAPTER XLI. 
Naso-Pharyngeal Catarrh, 288-298 

CHAPTER XLII. 

Hypertrophy of the Pharyngeal Tonsil, or Adenoid Growths in the Vault 

of the Pharynx, 299-315 

CHAPTER XLIII. 
Fibroma of the Naso-Pharynx. 316-322 

CHAPTER XLIV. 
Myxo-Fibroma of the Naso-Pharyux, 323-326 

CHAPTER XLV. 
Chondroma of the Naso-Pharynx, 327 

CHAPTER XLVL 
Sarcoma of the Naso-Pharynx, 328-330 

CHAPTER XL VII. 
Carcinoma of the Naso-Pharynx, . . . . . . . . 331 



CONTENTS. IX 



SECTION III. 

External Surgery of the Nose. 

CHAPTER XLVIII. 

PAGE 

External Surgery of the Nose, 335-363 

Marine's Operation, 335 

Maisonneuve's Operation, 336 

Nelaton's Operation, 336 

Botrel's Operation, 337 

Richard's Operation, 337 

Sedillot's Operation, 337-338 

Dezeanneau's Operation, 338 

Dieffenbach's Operation, 338-339 

Lariche's Operation, 339-340 

Rouge's Operation, 340 

Palasciano's Operation, 340-341 

Boeckel's Operation, 341-342 

Ollier's Operation, 342-343 

Lawrence's Operation, 343-344 

Langenbeck's Operation for Resection of the Nasal Bone, . . 344-346 

Linhart's Operation, 346 

Brim's Operation, 346-347 

Fournaux- Jordan's Operation, 348 

Huguier's Operation, 348-350 

Cheever's Operation, 350-351 

Cheever's Double Operation, 351-352 

Waterman's Operation, 352 

Roux's Operation, 352-854 

Annandale's Operation, 354 

Langenbeck's Operation for the Temporary Resectiou of the Upper 

Portion of the Superior Maxilla, 354-356 

Billroth 's Operation for the Temporary Resection of the Superior 

Maxilla, 356-357 

Boeckel's Operation 357 

Demarquay's Operation, 357-358 

Maisonneuve's Operation, 358-360 

Pean's Operation, 360-361 

Berard's Operation, 361-362 

Huguier's Operation 362 

Vallet's Operation, 362-363 



X CONTENTS. 

SECTION IV. 

Diseases of the Fauces. 

CHAPTER XLIX. 

PAGE 

The Anatomy of the Fauces, ... . 367-377 

The Oro-Pharynx, 367-371 

The Soft Palate, Uvula, and Pillars of the Fauces, .... 371-374 

The Tonsils, . .'...' . . 375-377 

CHAPTER L. 

The Physiology of the Fauces, 378-380 

Deglutition, 378-379 

The Function of the Tonsils, 379-380 

CHAPTER LI. 
Acute Pharyngitis '. 381-387 

CHAPTER LII. 
Chronic Pharyngitis, 388-390 

CHAPTER LIII. 
Chronic Follicular Pharyngitis, 391-398 

CHAPTER LIV. 
Acute Infectious Phlegmon of the Pharynx, 399-403 

CHAPTER LV. 
Retro-Pharyngeal Abscess, 404-410 

CHAPTER LVI. 
Acute Uvulitis, 411-413 

CHAPTER LVII. 
Elongated Uvula, 414-417 

CHAPTER LVIII. 
Quinsy, or Peritonsillar Abscess, 418-429 

CHAPTER LIX. 

Hypertrophy of the Tonsils, . . . . . . . 430-445 

CHAPTER LX. 
Croupous Tonsillitis, or Acute Follicular Tonsillitis, .... 446-453 

CHAPTER LXI. 
Tonsilliths, 454-456 



CONTEXTS. 



XI 



CHAPTER LXII. 

PAGE 

Mycosis of the Fauces, 457-461 

CHAPTER LXIII. 
Hypertrophy of the Lingual Tonsil, 462-466 

CHAPTER LXIV. 
Diphtheria, 467-495 

CHAPTER LXV. 

Syphilis of the Fauces, 496-511 

The Primary Lesion, . 496-498 

Erythema of the Fauces, 498-499 

The Mucous Patch, 499-501 

The Superficial Ulcer, 501-502 

The Gummy Tumor, 502-503 

The Deep Ulcer of Syphilis, 503-505 

Cicatricial Deformities of the Fauces, 505-507 

Treatment of Syphilis in the Fauces, ....... 5018-51 

CHAPTER LXVI. 
Tuberculosis of the Fauces, 512-520 

CHAPTER LXVII. 
Lupus of the Fauces, 521-528 



CHAPTER LXV III. 



Foreign Bodies in the Fauces, 



529-531 



CHAPTER LXIX. 
Neuroses of the Fauces, 

Abnormalities of Sensation, 

Neuralgia, 

Reflex Neuroses, .... 
Spasmodic Disturbances, or Chorea, 
Myopathic Paralysis, . 
Paralysis due to Bulbar Lesion, . 
Herpes of the Fauces, . 



533-543 

532 
532-533 

533 
533-534 
534-536 
536-541 
541-543 



CHAPTER LXX. 

Benign Tumors of the Fauces, 544-550 

Tumors of the Soft Palate, Uvula, and Pillars of the Fauces, . , 544-548 

Tumors of the Tonsil, 549-550 

Tumors of the Oro-Pharynx, 550 



CHAPTER LXXI. 

Sarcoma of the Fauces, 

Sarcoma of the Soft Palate and Pillars of the Fauces, 

Sarcoma of the Tonsil, 

Sarcoma of the Pharynx, 



551-560 
551-553 
553-557 

557-560 



Xll 



CONTENTS. 



CHAPTER LXXII. 



Carcinoma of the Fauces, . 

Carcinoma of the Soft Palate, 
Carcinoma of the Tonsil, 
Carcinoma of the Pharynx, 



PAGE 

561-572 
561-563 
563-569 
569-572 



SECTION V. 



Diseases of the Larynx. 



CHAPTER LXXIII. 



The Anatomy of the Larynx, 
The Cartilages, 
The Ligaments, . 
The Cavity of the Larynx, 
The Muscles, 
The Mucous Membrane, 
The Arteries, 
The Veins, . 
The Lymphatics, . 
The Nerves, . 



575-593 
575-579 

579-580 
580-583 
583-588 
588-589 
589-590 
590 
590-591 
591-593 



CHAPTER LXXIV. 

The Physiology of the Larynx, . . . 594-599 

The Function of the Larynx in Respiration, . . .. . . 594-595 

The Function of the Larynx in Phonation, 595-598 

The Singing Voice, ..... ... 598-599 

CHAPTER LXXV. 

Laryngoscopy, 600-607 

CHAPTER LXXVI. 

Acute Laryngitis, . 608-613 

CHAPTER LXXVII. 

Acute Laryngitis in Children, 614-623 

Acute Supraglottic Laryngitis, 614-616 

Acute Subglottic Laryngitis, , 616-623 

CHAPTER LXXVIII. 

Chronic Laryngitis, 624-637 

Chronic Catarrhal Laryngitis, 624-632 

Chronic Subglottic Laryngitis, ....;... 632-635 

Trachoma of the Larynx, or Chorditis Tuberosa, .... 635-637 

CHAPTER LXXIX. 

Laryngitis Sicca, . . . 638-641 



CONTENTS. xin 

CHAPTER LXXX. 

PAGE 

Acute Phlegmonous Laryngitis, or (Edematous Laryngitis, . . . 642-645 

CHAPTER LXXXI. 
(Edema of the Larynx, 646-649 

CHAPTER LXXXIL 
Croupous Laryngitis, 650-655 

CHAPTER LXXXIII. 
Perichondritis of the Laryngeal Cartilages, 656-663 

CHAPTER LXXXIV. 
Laryngeal Hemorrhage, 664-666 

CHAPTER LXXXV. 

Syphilis of the Larynx, . . . . . . . 667-679 

The Primary Lesion, 667 

Erythema of the Larynx, 667-668 

The Mucous Patch, 669 

The Superficial Ulcer, 669-670 

The Gummy Tumor, 670-671 

The Deep Ulcer, 671-673 

Cicatricial Stenosis, 673-675 

Treatment of Laryngeal Syphilis, ....... 676-679 

CHAPTER LXXXVI. 
Tuberculosis of the Larynx, 680-692 

CHAPTER LXXXVII. 
Lupus of the Larynx, 693-694 

CHAPTER LXXXVIII. 

Neuroses of the Larynx, 695-723 

Hyperesthesia, .... ...... 695 

Anaesthesia, 695 

Paresthesia, 696 

Neuralgia, 696 

Paralysis of the Superior Laryngeal Nerve, 696-698 

Recurrent Laryngeal Paralysis 698-702 

Bilateral Parajysis of the Abductor Muscles, 702-708 

Unilateral Paralysis of the Abductor Muscles, 708-709 

Paralysis of Individual Muscles, 709-713 

Hysterical Aphonia 713-714 

Spasm of the Glottis, 714-715 

Spasm of the Glottis in Children, 715-718 

Spasm of the Glottis in Adults, . • 718-722 

Chorea of the Larynx, 722-723 

Dysphonia Spastica, 723 

Laryngeal Vertigo, . 723-725 



Xiv CONTENTS. 

CHAPTER LXXXIX. 

PAGE 

Foreign Bodies in the Air Passages, ........ 726-733 

CHAPTER XC. 
Fractnre of the Larynx, ... ...... 734-736 

CHAPTER XCI. 
Prolapse of the Laryngeal Ventricles, ......... 737 

CHAPTER XCII. 
Benign Tumors of the Larynx, ......... 738-751 

CHAPTER XCIII. 
Sarcoma of the Larynx, . 752-754 

CHAPTER XCIV. 
Carcinoma of the Larynx, . 755-759 

SECTION VI. 

External Surgery of the Throat. 

CHAPTER XCV. 

Pharyngotoray, 763-770 

Subhyoid Pharyngotomy, ......... 763-765 

Lateral Pharyngotomy, 765-770 

CHAPTER XCVI. 
Thyrotomy, 771-77 

CHAPTER XCVII. 
Tracheotomy, 775-790 

CHAPTER XCVIII. 
Extirpation of the Larynx, 791-798 

CHAPTER XCIX. 
Resection of the Larynx, 799-800 



LIST OF ILLUSTRATIONS. 



Movement 



FIGURE PAGE 

1. Throat Mirrors, Actual Size, 4 

2. The Author's Head-band and Mirror, .... 

3. Mackenzie's Light Condenser, Mounted upon a Ratchet 

Gas Fixture, 

4. Frankel' s Nasal Speculum, 

5. Goodwillie's Nasal Speculum, 8 

6. The Author's Self-retaining Nasal Speculum, Actual Size, . . 9 

7. Method of Making an Examination of the Anterior Nares by Means 

of Sunlight, the Head of the Patient being in Position for the 
Inspection of the Inferior Meatus 9 

8. Anterior Rhinoscopy, the Head of the Patient being in Position for 

the Inspection of the Middle Turbinated Body, . . . .10 

9. Anterior Rhinoscopy, Position of the Head for Inspecting the Wall 

of the Pharynx, through the Nasal Passages, 11 

10. Turck's Tongue Depressor, 12 

11. The Author's Tongue Depressor, 12 

12. Method of Making a Posterior Rhinoscopic Examination, . . .13 

13. White's Self-retaining Palate Retractor, 14 

14. The Posterior Nares, . 15 

15. Post-Nasal Syringe, 18 

16. Method of Using the Nasal Douche, 19 

17. Sass' Spray Tube, 20 

18. The Ordinary Single-Bulb Hand-Ball Atomizer fitted for Nasal Ap- 

plications, 21 

19. Delano's Atomizer, . .21 

20. Mackenzie's Inhalator, 22 

21. Large Globe Inhaler for Inhaling Fluids Atomized by Means of Com- 

pressed Air, 23 

22. Diagrammatic Section of Mucous Membrane, 25 

23. Outer Wall of Left Nasal Cavity, the Inferior and Middle Turbinated 

Bones having been Removed, 42 

24. The Olfactory Cells in Man, 45 

25. Section of the Cavernous or Erectile Tissue of the Middle and Lower 

Turbinated Bones, Inflated and Dried, 47 

26. Microscopical Characters of Hypertrophic Rhinitis, . . . .75 

27. Large Masses of Hypertrophied Membrane on the Posterior Termi- 

nation of Lower Turbinated Bones, More or Less Completely 
Filling the Posterior Nares 78 

28. The Author's Chromic-Acid Applicator, 82 

29. Gal vano- Cautery Handle with Flat Electrode for Use upon the 

Turbinated Tissues, 84 



xvi LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

30. Nasal Electrodes, 84 

31. Jarvis' Wire-Snare Ecraseur, 86 

32. Lateral View of Posterior Hypertrophy of the Mucous Membrane of the 

Lower Turbinated Bone, with Jarvis' Snare in Position for Section, 87 

33. Blandin's Septal Punch, 165 

34. Steele's Septal Punch, 165 

35. Adams' Forceps for Refracturing a Deflected Septum, . . . 166 

36. Adams' Nasal Clamp, 166 

37. Adams' Nasal Plugs, 166 

■38. Burrs for the Removal of Septal Deformities, 167 

39. Curtis' Nasal Trephines, 167 

40. The Author's Nasal Saw, 168 

41. Dislocation of the Columnar Cartilage of the Nose into the Right 

Nostril, 170 

42. Microscopical Appearance of Rhino-scleroma, 214 

43. Nasal Polypi, 218 

44. The Author's Snare, 222 

45. McKay's Forceps, 224 

46. Papilloma of the Nasal Mucous Membrane, 235 

47. Transverse Section of the Maxillary Sinuses, showing the Roots of the 

Molar Teeth Projecting into the Cavities through the Floor, . . 252 

48. Silver Drainage Tube for Antrum, .... • 259 

49. Anel's Lachrymal Syringe for Use in Disease of the Antrum, . . 259 

50. The Glandular Structures at the Vault of the Pharynx, .... 282 

51. Glandular Structures of the Pharyngeal Vault, seen in Anteroposterior 

Section, 282 

52. The Author's Porte-Caustique for Pharyngeal Vault, .... 296 

53. Electrode for the Naso-Pharynx, to be Manipulated through the Nasal 

Passages, 298 

54. Face, illustrating the Facial Expression Characteristic of the Existence 

of an Hypertrophied Pharyngeal Tonsil, 304 

55. The Author's Electrode fitted with a Shield for Use in the Pharyngeal 

Vault, * . . . . . .309 

56. Straight Electrodes for the Application of the Galvano-Cautery to the 

Pharyngeal Tonsil through the Nasal Cavity, 309 

57. Lowenberg's Forceps, 310 

58. The Author's Sharp Curette for the Pharyngeal Vault, . . . .311 

59. Hooper's Instruments for the Removal of Hypertrophied Pharyngeal 

Tonsils, 312 

60. The Author's Modification of Jarvis' Snare Ecraseur for the Removal 

of an Hypertrophied Pharyngeal Tonsil 314 

61. Lines of Bony Section in Nelaton's Operation, 336 

62. Sedillot's Operation ; Lines of Bony Section, 338 

63. Dezeanneau's Operation ; Lines of Section of Hard Palate, . . . 338 

64. Dieffenbach's Operation ; Line of Cutaneous Incision, .... 339 

65. Lariche's Operation ; Lines of Cutaneous Incision, .... 339 

66. Line of External Incision in Palasciano's Operation, .... 341 

67. Line of Cutaneous Incision in Boeckel's Operation, .... 342 

68. Line of Bony Section in Boekel's Operation, 342 

69. Line of Cutaneous Incision in Ollier's Operation, . . . . . 343 

70. Line of Bony Section in Ollier's Operation, 343 



LIST OF ILLUSTRATIONS. 



XVll 



FIGURE 

71. Line of Cutaneous Incision in Lawrence's Operation, 
Line of Bony Section in Lawrence's Operation, 
Line of Cutaneous Incision in Langenbeck's Operation 
Lines of Bony Incision in Langenbeck's Operation, 
Lin^s of Cutaneous in Langenbeck's Later Operation, 
Lines of Cutaneous Incision in Brans' Operation, . 
Lines of Bony Section in Brun's Operation, . 
Lines of Cutaneous Incision in Fournaux- Jordan's Operation, 
Lines of Cutaneous Incision in Huguier's Operation, 
Lines of Bony Section in Huguier's Operation, 
Line of Cutaneous Incision in Cheever's Operation, 
Lines of Bony Section in Cheever's Operation, 
Lines of Cutaneous Incision in Cheever's Double Operat 
Lines of Bony Section in Cheever's Double Operation, 
Lines of Cutaneous Incision in Roux's Operation, . 
Lines of Bony Section in Roux's Operation-, . 
Line of Bony Section of Palate in Roux's Operation, 
Lines of Cutaneous Incision in Langenbeck's Operation 
Lines of Bony Section in Langenbeck's Operation, 
Lines of Cutaneous Incision in Billroth 's Operation, 
Lines of Bony Section in Billroth's Operation, 
Lines of Cutaneous Incision in Demarquay's Operation 
Lines of Bony Section in Demarquay's Operation, 
Line of Bony Section in Maisonneuve's Operation, 
Lines of Bony Section in Maisonneuve's Operation, 

96. Line of Cutaneous Incision in Pean's Operation, 

97. Line of Bony Section in Pean's Operation, 

98. Lines of Bony Section in Pean's Operation, . 
Line of Cutaneous Incision in Berard's Operation, 
Lines of Bony Section in Berard's Operation, 
Lines of Bony Section in Huguier's Operation, 
Lines of Bony Section in Vallet's Operation, 
The Muscles of the Soft Palate and Pharynx, 
Mathieu's Tonsillotome, .... 
Mackenzie's Tonsillotome, 

106. Method of Using Mathieu's Tonsillotome, 

107. The Author's Snare for the Removal of Enlarged Tonsils, 
Enlarged Lingual Tonsil as Seen in the Laryngoscopic Mirror 
O'Dwyer's Intubation Tube Attached to Introducer, Ready for Use 
Extractor for the Removal of O'Dwyer's Tube, 

Mouth Gag, 

Scale for Intubation Tubes, 

The Cartilaginous Frame of the Larynx, with the Hyoid 

Ligamentous Attachments, 

The Cricoid, Seen Anteriorly, 

The Cricoid, Upper Surface, 

The Thyroid, Anterior Aspect, 

The Anterior Face of the Arytenoid 

The Posterior Face of the Arytenoid, .... 

Antero- posterior Section of the Larynx, showing the Cavity after 

Removal of the Mucous Membrane from the Left Lateral Half, 



72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 
83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 
93. 
94. 
95. 



99 
100 
101 
102 
103 
104 
105 



108, 
109. 
110. 
111. 
112. 
113. 

114. 
115, 
116 

117 
118 
119 



Bone and 



the 



PAGE 

344 
344 
345 
345 
346 
347 
347 
348 
349 
349 
350 
350 
351 
351 
352 
353 
353 
355 
355 
356 
356 
358 
358 
359 
359 
360 
361 
361 
362 
362 
363 
363 
369 
438 
439 
440 
444 
464 
491 
492 
492 
492 

576 
576 
576 

577 
578 
578 

581 



XVlll LIST OF ILLUSTRATIONS. 

FIGURE PAGE 

120. The Cricothyroid Muscle, viewed Anteriorly, 584 

121. The Arytenoid and Posterior Crico-arytenoid Muscles, .... 584 

122. The Glottis-Opening Action of the Posterior Crico-arytenoid Muscles, 

shown by Diagram, . 585 

123. The Glottis-Closing Action of the Lateral Cricoid-arytenoid Muscles, 

shown Diagrarnmatically, 585 

124. Arterial Supply of the Larynx, Posterior View, showing the Distribu- 

tion of the Superior Laryngeal Artery 588 

125. Arterial Supply of the Larynx, Anterior View, showing the Distribu- 

tion of the Inferior Laryngeal, with the Origin of the Superior 

Laryngeal Artery, 589 

126. Method of Making a Laiyngoscopic Examination, ..... 601 

127. Diagram showing the Principle of Laryngoscopy, 602 

128. The Laryngoscopic Image during Respiration, 604 

129. The Laryngoscopic Image during Phonation, 604 

130. Chronic Subglottic Laryngitis, 634 

131. Trachoma of the Right Vocal Cord, , . 636 

132. Crust Lying in the Ventricle in Laryngitis Sicca, ..... 639 

133. Acute Phlegmonous Laryngitis, 644 

134. Laryngeal Knives, 645 

135. (Edema of the Larynx, .... 648 

136. Laryngoscopic Image in Perichondritis of the Cricoid Cartilage, . . 660 

137. Gummy Tumor of Left Vocal Cord, 670 

138. Destruction of Epiglottis from Syphilitic Ulceration, .... 672 

139. Cicatricial Stenosis of the Larynx, the Result of Syphilitic Ulceration, 675 

140. Mackenzie's Laryngeal Dilator, Open, 677 

141. Navratil's Laryngeal Dilator, 678 

142. Tuberculosis of the Larynx, with Infiltration of the Epiglottis, . . 684 

143. Tuberculosis of the Larynx, Infiltration of Epithelial Layer with Mili- 

ary Tubercles, 684 

144. Extensive Tuberculous Ulceration of the Larynx, 685 

145. Lupus of the Larynx (Author's Case), 693 

146. Bilateral Paralysis of the Superior Laryngeal Nerve, .... 697 

147. Unilateral Paralysis of the Superior Laryngeal Nerve, .... 697 

148. Cadaveric Position of the Cords, as in Bilateral Paralysis of the Recur- 

rent Laryngeal Nerve, 700 

149. Right Recurrent Paralysis during Phonation, 701 

150. Right Recurrent Paralysis during Inspiration, 701 

151. Transverse Section of the Larynx, illustrating the Valve-like Action of 

the Cord in Bilateral Paralysis of the Abductors, .... 705 

152. Bilateral Paralysis of the Abductor Muscles, 706 

153. Paralysis of the Left Internal Tensor, 710 

154. Paralysis of the Arytenoideus Muscle, 711 

155. Cusco's Laryngeal Forceps, • • 730 

156. Coin in the Laryngeal Ventricle, 731 

157. Coin in the Grasp of the Forceps, Showing the Method of Removal, . 731 

158. Minor's Tracheal Retractor, 732 

159. Gross' Tracheal Forceps, 732 

160. Seller's Tube Forceps, • .733 

161. Papilloma of Right Ventricalular Band, . . . . . .743 

162. Papilloma of Ventricalular Bands, . . . . • • • • 743 



LIST OF ILLUSTRATIONS. XIX 

FIGURE PAGE 

163. Papilloma of Ventrical Bands, Completely Filling the Vestibule of the 

Larynx, 744 

164. Cystoma of the Epiglottis, 744 

165. Chondroma of the Epiglottis, 745 

166. Angioma of the Left Ary-epiglottic Fold, 745 

167. Mackenzie's Laryngeal Forceps, 746 

168. The Cutaneous Incision in Subhyoid Pharyngotomy, and the Relation 

of the Deeper Parts 764 

169. Line of Cutaneous Incision in Lateral Pharyngotomy (Langenbeck's 

Method), 765 

170. Line of Cutaneous Incision in Lateral Pharyngotomy (Bergmann's 

Method), 766 

171. Line of Cutaneous Incision in Lateral Pharyngotomy (Bolster's Method) , 767 

172. Line of Cutaneous Incision in Lateral Pharyngotomy (Mickulicz's 

Method), 768 

173. Line of Cutaneous Incision in Lateral Pharyngotomy (Cheever's 

Method), 769 

174. Line of Cutaneous Incision in Lateral Pharyngotomy (Polaillon's 

Method), 770 

175. The Cutaneous Incision in Thyrotomy, and its Relation to the Underly- 

ing Structures, 772 

176. Trousseau's Tracheal Tube, 775 

177. Durham's Tracheal Tube, with Inner Tube and Pilot Trocar, . . 776 

178. Koenig's Tube for the Relief of Tracheal Obstruction, . . . .777 

179. Tracheotomy Tube Fitted with Luer's Valve, 778 

180. Diagram showing the Relations between the Larynx and Trachea and 

the Great Vessels of the Neck, 780 

181. Diagram showing the Line of Cutaneous Incision in Infra-thyroid 

Tracheotomy, and the Relation of the Underlying Structures, . 784 

182. Diagram showing the Cutaneous Incision for Opening the Air Passages 

above the Thyroid Isthmus, and the Relation of the Underlying 
Structures, 787 

183. Trendelenburg's Apparatus . 792 

184. Gerster's Tampon Canula, 793 

185. Line of Cutaneous Incision for Excision and Resection of the Larynx, 

with the Relative Position of the Deeper Structures, . . . 794 

186. Gussenbauer's Artificial Vocal Apparatus, 797 



SECTION I. 

DISEASES OF THE NASAL PASSAGES. 



DISEASES OF THE NASAL PASSAGES. 



CHAPTER I. 

METHODS OF EXAMINING THE UPPER AIR PASSAGES. 

The essential physiological process by which the human voice is 
produced in the larynx, its pitch regulated, and its volume and other 
qualities governed, was a source of speculation even in the earliest 
days of medicine, and the ingenuity of many able investigators, such 
as Bozzini, Babington, Bennati, Avery, and others, was exercised to 
devise special appliances by which the movements of the vocal cords 
might be seen. None of these devices proved successful, however, 
until, among others, Manuel Garcia, a distinguished teacher of vocal 
music in London, interested himself in the subject. He obtained a 
view of his own larynx and the results of his investigations of the 
function of the vocal cords in phonation he presented before the 
Royal Society of London in a paper entitled "Physiological Ob- 
servations on the Human Voice." 

Garcia's method was exceedingly simple. An ordinary dental 
mirror, inclined at a proper angle, was placed well back in the fauces 
in such a manner that it should receive the direct rays of sunlight, 
while, at the same time, the visual image was reflected back in the 
same direction and perceived by Garcia in a hand-mirror held before 
his eyes. Garcia's obervations were published merely as a contribu- 
tion to vocal physiology. Tiirck, of Vienna, however, soon after, 
becoming acquainted with Garcia's experiment, conceived the idea 
that this method might be employed for the diagnosis of laryngeal 
disease. He failed to improve on Garcia's simple manipulation, and 
accomplished no encouraging results. Czermak, of Pesth, however, 
took up the matter where Tiirck left off, and, improving on his 
methods, succeeded in demonstrating conclusively that this device 
might be made to render the greatest possible service to medical 



4 DISEASES OF THE NASAL PASSAGES. 

science, both as a means of diagnosis and as suggesting improved 
methods of treatment of diseases of the upper air passages. Czer- 
mak's success was due entirely to the fact that, discarding sunlight, 
he resorted to the use of artificial light, which was managed after the 
manner already suggested by Helmholtz and perfected by Eeute. 



The Laryngoscope. 

This term is used to designate the special illuminating apparatus 
by which the upper air passages are examined, and of course applies 
equally to rhinoscopy and laryngoscopy. The essential feature in 
the examination of the upper air passages is the projection of a pow- 
erful light through the anterior nares for the practice of so-called 
anterior rhinoscopy, or into the open mouth for the inspection of the 
pharynx, or so-called pharyngoscopy. In addition to this, as in 
laryngoscopy and posterior rhinoscopy, small mirrors are introduced 
into the fauces, by which the illuminating rays are deflected to those 
parts which are without the line of direct vision. 




Fig. 1.— Throat Mirrors, Actual Size, from No. 0, % inch in diam., to No. 5, 1 inch in diam. 

The essential parts of the laryngoscopic apparatus then are : 1. 
The laryngoscopic or rhinoscopic mirror. 2. The source of illumi- 
nation, or the light. 3. The concave reflecting mirror. 

The Throat Mirror. — The laryngeal mirror is a small round mirror 
with a German-silver frame, and attached by its rim to a slender wire 
stem at varying angles, the whole measuring from six to seven inches 
in length. They are made from three-eighths to one inch in diameter. 
The best mirrors are made of very thin glass and with a narrow rim 
such as will afford the largest reflecting surface to the smallest bulk, 
the stem being sufficiently stout to admit of the application of con- 
siderable force without bending. 

The, Light. — The illumination may be derived from the sun, the 
oxygen-hydrogen light, a gas-jet, or an ordinary coal-oil lamp. If 
gas is used, the Argand burner gives undoubtedly the better and 
steadier light, although ordinarily a coal-oil lamp is quite satisfac- 



METHODS OF EXAMINING THE UPPER AIR PASSAGES. 



tory in giving a whiter and more intense light than the usual city gas 
supply, and of these undoubtedly the best is one mounted either with 
the Duplex or Rochester burner. Sajous states that the whiteness of 
this light may be increased by dropping a small piece of camphor into 
the oil, a suggestion which I have verified. The direct rays of the 
sun afford by far the best source of illumination, and should always 
be used where available, and especially in the first examination of the 
case. Unfortunately we have not always the sunlight, and any one 
devoting his attention to this branch of medicine should make use of 
the oxyhydrogen light, since it is only by those powerful illumina- 
tors that the parts are brought fully under that nicer inspection 
which enables us to make a thorough diagnosis. Lennox Browne 
was, I believe, the first to devise an apparatus of this kind suitable 
for office work. His apparatus is, however, unnecessarily compli- 
cated. Sajous speaks very highly of the so-called albo-carbon light 
which consists of a metal globe containing a material called albo- 
carbon, located in such a way that it is subjected to the heat of the 
flame, while at the same time the gas passes through it before com- 
bustion. This undoubtedly gives a very brilliant white light. The 
incandescent electric light offers no advantages over the ordinary gas- 
jet or coal-oil lamp. The various devices by which a small incan- 
descent light is attached to a throat mirror, modelled after Trouve's 
polyscope, I think are to be regarded as mere playthings and of no 
practical value. The same may be said also of the incandescent 
light attached to the head-band. 
The Reflecting Mirror.— The 
really important feature of every 
laryngoscopic apparatus is the 
concave reflecting mirror of 
Reute, since it is by this device 
that the rays of light are suf- 
ficiently converged to thoroughly 
illuminate a part, even if the 
light is not particularly intense, 
and furthermore it enables us to 
manipulate and direct the illu- 
minating rays at our conveni- 
ence. Whatever part is to be 
examined, it is absolutely nec- 
essary that this concave mirror 
be perforated in the centre, that the illuminating rays and visual 
rays shall be exactly in the same line. This mirror may be attached 
to a simple head-band carried on the forehead, or it may be attached 




Fig. 2.— The Author's Head-Band and Mirror. 



6 DISEASES OF THE NASAL PASSAGES. 

to a fixed apparatus. The head-mirrors in use are rather heavy and 
large. As a matter of fact the lighter the mirror the better, and for 
this reason I much prefer a smaller-sized mirror which possesses all 
the advantages and none of the disadvantages of the ]arger ones. 
Fig. 2 shows the writer's head-mirror; it is two and a half inches in 
diameter, with the knob attached to the periphery of the frame which 
gives unrestricted movement to the mirror. In addition to this, the 
split socket is only of sufficient size to receive the knob, while the 
plate to which the socket is attached is but one and a half inches 
long. 

The band is made of half-inch alpaca braid, which is far superior 
to elastic, is worn with much more comfort, and possesses sufficient 
elasticity to maintain the instrument firmly in place. In addition to 
this, the whole affair is perfectly flat and is carried easily in the vest 
pocket. 

The Fixed Appakatus. 

In the early days of laryngoscopy the idea seems to have prevailed 
that this art could only be practised by means of a somewhat elaborate 
apparatus. This idea, I think, had its impetus largely in the intro- 
duction of Tobold's instrument, which seems to be the pattern on 
which most of the later laryngoscopes were constructed. Tobold's 
apparatus, though much used, has no practical advantage over a simple 
head-mirror, which, with a good, strong source of light, affords us as 
good a method of practising laryngoscopy as the most elaborate 
apparatus. 

Mackenzie's light condenser shown in Fig. 3 is a simple and 
useful apparatus, and consists of an upright metal cylinder about 
three inches in diameter, with a fenestra in the side, into which a 
plano-convex lens two and a half inches in diameter and comprising 
about one-third of a sphere is fitted. The whole may be easily fitted 
over a coal-oil lamp or gas jet. 

I regard the use, however, of an elaborate laryngoscopic apparatus 
unnecessary, as examinations can be thoroughy made by means of a 
head-mirror and a good light. 

The Examination. 

The best source of illumination is sunlight. These rays are uti- 
lized in the small device shown in Fig. 7 which consists of a 
plane mirror, about four inches in diameter, mounted on an upright 
support, to which it is attached by a universal joint. This may be 



METHODS OF EXAMINING THE UPPER AIR PASSAGES. 



placed in a window, exposed to the sun, and turned in such a direc- 
tion that its rays shall be deflected upon the concave reflecting mirror 
of a fixed apparatus, or in such a direction that they fall upon the 
forehead-mirror of the operator, as shown in the same illustration. 
In making use of sunlight, the unpleasant effect of the rays striking 
directly upon the eye, is easily avoided by placing the heliostat a 
few feet above the right shoulder of the patient 
and in such a manner that the rays shall fall at I ; ^ 
an angle of about forty-five degrees upon the I r / \ 
mirror. ; ' LA' ;/ 

In the absence of sunlight, a very satisfac- '^~.z:p 




Fig. 3. 



tory examination can be made 
by the aid of an ordinary coal- 
oil lamp or gas jet. 

In making an examination 
with Sass' or Tobold's laryn- 
goscope, the instrument is 
placed on the right of the 
patient and at about the ele- 
vation of the face, and the 
reflecting mirror is brought 
into such a position as 
to intercept the illuminating 
rays and deflect them upon the face of the patient. 

In using Mackenzie's condenser, the patient is placed in much 
the same way and the rays of light are made to fall upon the head- 
mirror of the operator. The ratchet-movement gas fixture, shown in 
Fig. 3, is a convenient mounting, the lenses being easily adjusted to 
the level of the mirror on the forehead of the operator. In using this 
instrument, one's movements are somewhat hampered, as the head 
has to be held in one position, which is necessarily somewhat weari- 
some, whereas with the unhooded lamp or gas jet, the rays can be 



-Mackenzie's Light Condenser Mounted upon a 
Ratchet-Movement Gas Fixture. 



8 DISEASES OF THE NASAL PASSAGES. 

easily intercepted in whatever position or at whatever level the head 
of the operator may be. After all, any method of examination is 
largely a matter of preference on the part of the operator, and the ]ess 
complicated the procedure and the apparatus the better. 

A special operating-chair is recommended by many authorities, 
but I think an ordinary straight-back chair is much to be preferred, 
and it enables the surgeon in operating outside his office to adapt 
himself more readily to improvised conveniences. 

Khinoscopy. 

The nasal cavity is examined by illumination and direct inspec- 
tion through the nostrils, called anterior rhinoscopy, and also by 
placing mirrors in the fauces so that the rays of light are reflected 
through the posterior nares. This is known as posterior rhinoscopy. 

Anterior Rhinoscopy. — This examination is made by dilating the 
flexible portions of the nostrils by means of a suitable speculum, and 
illuminating the cavity by means of light reflected from the concave 





Fig. 4.— Frankel's Nasal Speculum. Fig. 5.— Goodwillie's Nasal Speculum. 

mirror, so placed that the focus of illumination may fall as nearly as 
possible upon the part to be examined. 

A number of instruments have been devised for dilating the nostril 
for this inspection. In Fig. 4 is shown Frankel's instrument, com- 
posed of two blades regulated by a set screw. It is only partially 
self -retaining, however. Goodwillie's speculum, shown in Fig. 5, 
is a much simpler device, whose action is evident from the cut. Its 
third blade, however, it seems to me, accomplishes no good purpose. 
Elsberg has modified Delaborde's tracheal dilator by inserting a set 
screw to hold it open, thus adapting it for use as a nasal speculum. 
This is an instrument of undoubted value in cases in which the parts are 
rigid and require to be opened with considerable force. The objec- 
tion to this speculum is that it occupies one hand in its manipulation. 
Fig. 6 shows an instrument devised by the writer, in which the 
blades are placed at a right angle to the spring, and is so constructed 
that the instrument is thoroughly self -retaining, and holds the nostril 






METHODS OF EXAMINING THE UPPER AIR PASSAGES. 9 

open excellently well, while at the same time both hands are left 
free for other manipulations. When properly constructed, this in- 
strument has served a better purpose in my own hands than any of 
those mentioned. On much the same principle is a convenient little 
instrument devised by Jarvis. 




Fig. 6.— The Author's Self -retaining Nasal Speculum, actual size. 

In making an examination of the parts, the patient is placed with 
his face directly on a level with that of the operator, and, the speculum 
being inserted, the bridge of the nose is grasped firmly between the 




Fig. 7.— Method of Making an Examination of the Anterior Nares by Means of Sunlight, the Head 
of the Patient being in Position for the Inspection of the Inferior Meatus. 

index and second finger, while, at the same time, the tip of the patient's 
nose is tilted up by the thumb, with a considerable degree of force, 
as shown in Fig. 7, in order that the light from the head-mirror may 



10 



DISEASES OF THE NASAL PASSAGES. 



be thrown into and along the inferior meatus. The patient's head, 
now, is to be turned very slightly, first to one side and then to the 
other, enabling the operator to successively inspect the lower portion 
of the septum and the face of the lower turbinated body. After 
these have been thoroughy inspected, the head should be thrown 
backward, as seen in Fig. 8, until the lower border of the middle 
turbinated body is brought into view, when, by the same lateral 
motion of the patient's head, the face of this body and that portion of 
the septum opposite are brought successively into view. This back- 
ward motion being continued, there is brought under inspection the 




Fig. 8.— Anterior Rhinoscopy, the Head of the Patient being in Position for the Inspection of the 

Middle Turbinated Body. 

main portion of the middle turbinated body, and finally its anterior 
termination, and the vestibule of the nose. This inspection having 
been made as thoroughly as possible, a ten or twenty per cent, solu- 
tion of cocaine should be thrown in, and sufficient time allowed to 
elapse for the tissues to undergo thorough contraction, and the blood- 
vessels to become completely emptied, after which the same process 
should be gone through a second time. In this manner anterior 
rhinoscopy becomes of far greater importance even than posterior 
rhinoscopy, since by this means the whole of the nasal passages may 
be brought under examination, from the nostrils to the posterior 
nares, and after the membrane has been contracted by cocaine, a part 
of the glandular structure of the upper pharynx even can be inspected 
on both sides. By this means, information is obtained as regards the 
existence or degree of inflammatory action in the nasal mucous mem- 
brane covering the turbinated bones, the extent of hyperemia, the 



METHODS OF EXAMINING THE UPPER AIR PASSAGES. 11 

existence of deformities or deflections of the septum, the presence of 
polypi or other tumors, the character of the secretions of the part, 
whether mucus or pus, and the existence of ulceration, necrosis, etc. 
In looking directly down the nasal passages, the view of the lower 
turbinated body is very much fore-shortened, but when the cavity 
has been dilated with cocaine, as before stated, in many cases it is 
quite easy to recognize the posterior wall of the pharynx, as an elon- 
gated triangular patch, presenting a lighter color than that of the 
turbinated bodies. It is always easy to ascertain whether the 
pharynx is seen by this examination, by directing the patient to 




Fig. 9.— Anterior Rhinoscopy, Position of the Head for Inspecting the Wall of the Pharynx, 
through the Nasal Passages. 



swallow, or, better still, simply to enunciate the letter K, by which 
the levator palati muscle is brought into vigorous contraction, and 
thereby swings across the lower and outer portion of the posterior 
nares, the movement being easily recognized. The position of the 
head necessary for this inspection is shown in Fig. 9. 

Another method of examining the nasal cavities consists in dilat- 
ing each nostril by means of a speculum, after which the illuminating 
rays are projected into one cavity and against the septum, when the 
other cavity is to be inspected. It will be found that the septum is 
so thoroughly translucent that one of the nasal cavities will be fully 
illuminated by rays of light projected through it. The parts seen in 
this manner present quite a different picture from that shown by the 
direct illuminating rays, and information which it affords is not 
easily obtained by the ordinary procedure, the light being projected 
more directly into the recesses beneath the turbiaated bones, and any 



12 



DISEASES OF THE NASAL PASSAGES. 




variations from the normal are more easily recognized. In addition 
to this, transmitted light brings out in a striking manner the irregu- 
larities of contour in the septum itself. 

Posterior Rhinoscopy. — This examination is somewhat more difficult 
than that through the anterior nares, and requires therefore a nicer 

manipulative skill. In order that these parts 
may be brought into view, a mirror must be 
placed in the pharynx in such a way that 
light may be thrown up into the posterior 
nares, while, at the same time, the palate re- 
mains completely relaxed, and the tongue is 
prevented from protruding itself into the line 
of vision. Occasionally a patient is met with 
who will depress his own tongue in so satis- 
factory a manner as to tolerate the examina- 
tion without the aid of instruments. Ordi- 
narily, however, it is necessary to press the 
tongue down by means of the spatula. 
Tiirck's tongue depressor, shown in Fig. 10, 
though a somewhat elaborate and expensive 
instrument, is undoubtedly of value when the 
patient can manipulate the instrument him- 
self. It is usually, however, better for the 
operator to manage the spatula. Some form of the folding spatula 
is very convenient, since it can be carried in the pocket. 

Depressing the tongue by means of the spatula would seem to 
be one of the simplest of manipula- 
tions, and yet, if awkwardly done, the 
fauces may be so irritated that the 
examination may be entirely impos- 
sible ; on the other hand, if properly 
done, even an exceedingly irritable 
throat may be satisfactorily exam- 
ined. It should be borne in mind 
that if the tongue is pressed directly 
down upon the floor of the mouth, 
the root is pressed backward into the 
fauces, which is generally enough to 
cause more or less severe gagging. 
On the other hand, if the tongue is 
drawn forward by the spatula, it can 
be controlled without exciting involuntary movements. The spatula 
shown in Fig. 11 is well fitted to accomplish this purpose. The blade 



Fig. 10.— Tiirck's Tongue 
Depressor. 




Fig. 11.— The Author's Tongue Depressor. 



METHODS OF EXAMINING THE UPPER AIR PASSAGES. 13 



is a thin plate of metal three and a half inches long and one inch wide, 
tapering toward a handle, which is three inches in length and to 
which it is attached at a right angle. The slightly curved blade is 
fenestrated at its distal extremity to permit arching of the tongue into 

it, by which the organ is more 
firmly grasped. 

In introducing the tongue 
■, /: 7 depressor, its beak should al- 

ways be carried beyond the 
arch of the tongue, that is, be- 
yond the highest point at which 
the tongue is visible; other- 
wise, in pressing the organ 
downward, its anterior end will 






become depressed, while its centre 
will rise and interfere with the inspec- 
tion. [Furthermore, the beak of the 
spatula should be carried back to 
cover the arch of the tongue only; 
otherwise the pressure on the sensi- 
tive parts near the base of the tongue 
is liable to excite retching. The 
spatula should be held between the thumb and the forefinger, the 
thumb pressing against its angle, while the second finger passes un- 
der the chin of the patient. In this manner a grasp is maintained of 
the lower jaw, and control of the movements of the head secured. 
The tongue should be pressed downward and forward and the patient 



Fig. 12.— Method of Making a Posterior 
Rhinoscopic Examination. 



14 DISEASES OF THE NASAL PASSAGES. 

instructed to breathe through the nose, that the palate may be re- 
laxed. If retching occurs the examination should be abandoned. 

In any given examination the largest mirror should be selected 
which can be introduced without touching the parts. The rhinosco- 
pic mirror should be held lightly in the right hand (see Fig. 12), 
and passed backward somewhat edgewise, in order that it may go 
through the niche between the uvula and right pillar of the fauces 
without touching the parts. After it has reached the pharyngeal 
space behind the palate, by slightly rotating the handle from right to 
left between the fingers, the reflecting surface should be brought 
around so as to face the operator, and the mirror carried upward 
until its upper border is slightly hidden by the soft palate. The 
position of the mirror should now be at a right angle with the line of 
vision, and inclined slightly backward, the handle being held at one 
side, the shaft against the corner of the mouth, as seen in Fig. 12. 
The difficulty lies in the inability of the patient to control the palate, 
which if touched by the mirror is immediately drawn up against the 
posterior wall of the pharynx. The patient may be directed to 




Fig. 13.— White's Self -retaining Palate Retractor. 

breathe through the nose, but this is exceedingly difficult, as a rule, 
and the palate is more readily relaxed by uttering a nasal sound, such 
as "Eh," giving it as full a nasal twang as possible. If there is still 
difficulty in controlling the movements of the fauces, they should be 
anaesthetized by a ten or twenty per cent, solution of cocaine. This 
application is exceedingly unpleasant, giving rise to a curious sensa- 
tion of choking or suffocation, but it is never attended with anything 
more than a temporary inconvenience. 

As a last resort, other means failing to control the movements of 
the fauces, we may proceed to tie up the palate after the manner first 
suggested by Desgranges. This is done by passing a cord through 
each nostril to the pharynx, drawing it out through the mouth, when 
it is passed over the ear on each side and tied behind the head. The 
palate gradually yields to the traction and a broad space is afforded 
for inspection of the parts above. A soft rubber cord, as first sug- 



METHODS OF EXAMINING THE UPPER AIR PASSAGES. 15 

gested by Wales, about one-eighth of an inch in diameter and a 
yard long, is much better than an ordinary cord. If any difficulty is 
experienced in passing the cord, a small velvet-eyed English catheter 
may be used, the stylet being inserted for passing it through the 
nares. This procedure is quite easy and draws forward the palates 
very satisfactorily for inspection or treatment of the upper pharynx. 




Palate hooks, palate retractors, combination rhinoscopic mirrors 
with retractors, such as Duplay's instrument and other devices, I have 
never found of much value. The most useful instrument is that shown 
in Fig. 13. 

The Ehinoscopic Image. 

The mirror being placed in the position described, the oval-shaped 
openings of the posterior nares will be brought into view. This pos- 
terior rhinoscopic image is shown in Fig. 14 ; it should be borne in 
mind that these parts are seen only in detail and not as a whole. 
Separating the choanse, in the median line will be seen the septum, 
broad above and tapering to a sharp and narrow edge below. On 
each side of the septum will be seen, as dark cavities, the nasal pas- 
sages, with the turbinated bodies projecting into them from the 
outer wall of each. The superior turbinated body will be just visible, 
a light reddish band, in the upper part of the image, and seeming to 
slant upward and forward. Immediately below it, and separated 
from it in the posterior portion by a dark line, the superior meatus, 
is the middle turbinated body, appearing as an elongated and some- 
what fusiform projection, of a yello wish-red color. Below T this again 
may be seen a considerable portion of the middle meatus, and below 
this the upper half of the inferior turbinated body, of much the same 



16 DISEASES OF THE NASAL PASSAGES. 

color as the middle, and giving the impression of a somewhat 
elongated mass resting on the floor of the nares. The inferior meatus 
and floor of the nares cannot be brought into view. If, now, the 
mirror be turned a little to one side, the eminence surrounding 
the orifice of the Eustachian tube will be seen separated from the 
posterior wall of the vault of the pharnyx by the sinus of Rosen- 
miiller. The Eustachian tube is seen in profile and its orifice simply 
shows a dark line on a bright yellow background, the anterior wall of 
the depression leading into it. 

By changing the inclination of the mirror now to a more obtuse 
angle, there will be brought into view the dome-like cavity of the 
vault of the pharynx, presenting a somewhat irregular outline, the 
surface being marked by furrows and depressions which indicate the 
site of the pharyngeal tonsil ; the parts becoming smoother as the 
view passes down, until there is seen the deep red, smooth, shining 
surface of the mucous membrane of the lower pharnyx. In adult life, 
however, as we know, the glandular structures of the pharyngeal 
vault undergo a certain amount of atrophy, and hence are not prom- 
inently visible. In these cases we simply bring into view the smooth 
surface of the mucous membrane lining this cavity. This change in 
the inclination of the mirror is best accomplished by simply turning 
the handle in the fingers, as the attempt to accomplish it by elevating 
or depressing the hand is liable to end in causing retching. To 
obtain a complete inspection of the vault of the pharnyx, it will gen- 
erally be found best to change the mirror and use one mounted at an 
angle of 130°, the same used in making a laryngeal examination. 

This examination reveals the condition of the mucous membrane 
of the nasal cavity, the variety and extent of such hypertrophic 
thickening as may exist in nasal catarrh, the condition of the pharyn- 
geal tonsil, the extent of hypertrophy that may exist there, the 
character and amount of the secretions from the parts, the existence 
of tumors in the nose or vault, ulceration, necrosis, etc. 

As regards the nasal cavity, not much information is gained by 
this inspection that cannot be better obtained by anterior rhinos- 
copy. Morbid conditions of the septum, for instance, I have never 
seen shown in this way, except the hypertrophy of the mucous 
membrane on either side posteriorly, as the result of hypertrophic 
rhinitis. Ocasionally, however, small polypi well up beneath the 
middle turbinated body posteriorly are seen, where the anterior 
examination fails to reveal them. The pus discharged from the 
accessory sinuses can be recognized also in this manner, although 
usually this is best detected by the anterior examination. 



CHAPTER II. 

METHODS OF TREATING THE UPPER AIR PASSAGES 
BY MEANS OF INSTRUMENTS. 

In the local treatment of the mucous membrane of the upper air 
passages, various mechanical devices have been employed by which 
the parts were thought to be more thoroughly medicated. To this end 
various forms of brushes, sponge holders, douches, atomizers, etc., 
were devised, and in the earlier days of laryngoscopy a good deal of 
importance was attached to their use. I think no one will question, 
at the present time, that their value was greatly overestimated, and 
indeed, with our larger knowledge of the physiology and pathology 
of the mucous membranes of the upper air passages, our dependence 
upon these various instrumental aids has greatly diminished, and a 
large majority of them are thrown aside for the simpler methods. 

Insufflations. 

Snuffs and their application by means of specially devised instru- 
ments possess a certain value in the treatment of the upper air 
passages, and they are used by most physicians. They may be used 
by auto-insufflation or by special applicators. Pserhofer was among 
the first to devise a mechanical means of insufflation, and Rauchfuss 
to suggest an instrument by means of which powders are thrown into 
the upper air passages. The objection to all such tubes is that they 
deposit the powders in mass; this, however, is avoided by the in- 
sufflator of Ely, which deposits the powder in a smooth thin film, 
does not pile it on any one part, and carries it throughout the sinuous 
cavities. Stoerck's insufflator is used in connection with the com- 
pressed-air apparatus ; the distal point being placed in position to 
throw the powder in the desired direction, and the instrument con- 
nected with the air chamber, pressure on the valve lets on a sudden 
blast which drives the powder to the spot intended to be reached. 

The advantage of powders is their permanency of action; they 
remain for some time in contact with the part, become slowly dissolved 
in the mucus, and are absorbed by the membrane. The remedies 



18 



DISEASES OF THE NASAL PASSAGES. 




F.G. OTTO &.S0.MS. 



Fig. 15.— Post-nasal Syringe. 



usually employed in this form are tannin, bismuth, alum, borax, 
ferric alum, zinc, nitrate of silver, iodoform, opium, morphine, bella- 
donna, benzoin, sanguinaria, galanga, etc. To reduce the strength of 
an agent, it may be combined with pulv. cretse, pulv. acacise, magnesiae 
carbonas, sacch. alb., etc. If the powder is heavy, it may be rendered 
lighter by adding powdered starch or lycopodium. 

Douches. 

Fluids may be thrown against the diseased membrane of the 
larynx, pharynx, or nasal cavity by means of syringes and douches of 
different forms. Fig. 15 shows the ordinary post-nasal syringe, a 

common barrel 
syringe, fitted with 
a curved tube 
which terminates 
in a rose douche, 
delivering jets in 
every direction. For injections through the anterior nares, an ordi- 
nary ear syringe answers the purpose very well, but better still is the 
post-nasal syringe shown above, with the tube straightened. 

By nasal douche we mean the application of a continuous stream 
of water through the nasal cavities. 
The principle on which it acts was 
first suggested by Weber, who, in 
conducting a series of experiments 
on the sensibility of the nasal mu- 
cous membrane, observed that when 
a fluid was introduced into the nasal 
cavities the soft palate was lifted 
firmly against the posterior wall of 
the pharynx, and completely pre- 
vented the escape of the fluid into 
the pharynx. Acting on this idea, 
Thudicum introduced what is now 
known as the nasal douche. It con- 
sists of a reservoir from the bottom 
of which leads a rubber tube termin- 
ating in a rounded tip shaped to fit 
into the nostril. This tip being 
placed in the nostril and the reservoir 
raised, the head is bent over a bowl 
as shown in Fig. 16 ; the fluid then enters one nostril, and, passing 
around the posterior border of the septum, escapes through the other 




Fig. 16.— Method of Using the Nasal Douche. 



INSTRUMENTAL METHODS OF TREATMENT. 19 

in a continuous stream, reaching pretty thoroughly the whole of the 
mucous membrane of the two chambers. 

The value of the douche, as a means of applying cleansing fluids 
to the nasal cavity in certain cases, cannot be denied, especially in 
atrophic rhinitis, and perhaps syphilitic necrosis, but in the ordi- 
nary chronic inflammation with hypertrophy it is not only of no 
permanent value but may be mischievous, as first suggested by 
Koosa, who reported a number of cases of acute otitis media resulting 
from its use, attributing this accident to the entrance of fluids into 
the middle ear. I think it is to be borne in mind here that the very 
large proportion of patients affected by hypertrophic rhinitis of long 
standing suffer from a mild form of middle-ear disease. This acts 
as a predisposing cause of the acute form, which probably is pre- 
cipitated by the use of the douche. Considering this danger, and the 
fact that the douche accomplishes little if any good in hypertrophic 
rhinitis, its use in this affection should be condemned unreservedly. 
There is no such danger in atrophic rhinitis ; and I strongly advise 
the douche in this disease. 

Atomizers. 

The successful treatment of catarrhal affections being regarded as 
largely dependent upon the extent to which the parts might be reached 
by the medicament used, naturally led to the plan of reducing the solu- 
tions to a state of fine atomization, that they might be carried into the 
sinuous passages of the nasal cavities or thrown into the air passages 
below. In view of the very large extent to which the use of atomizers 
has grown in late years in the treatment of diseases of the upper air 
passages, it becomes a matter not only of historical but also of 
practical interest, to trace their development from the cruder devices 
of former days to the perfect instruments now provided for our use. 
The system was first put in practice at certain of the mineral springs 
of Europe when patients inhaled the spray from minuute jets of water 
projected against the walls of the chambers. Portable atomizers 
carrying out the same principle followed in due order, and have been 
modified by a succession of scientists, until finally Dr. Sass, of New 
York, constructed the atomizing tubes generally known as Sass' 
tubes. These are made on the Bergson principle, that if a current of 
air be driven through one tube placed at right angles to a similar tube 
which leads to a reservoir of water, a vacuum will be created by which 
the water will be drawn up into the vertical tube, until, meeting the 
current of air, it is broken up into a fine spray. They are of heavy 
barometer glass tubing, but instead of the two tubes being placed 



20 



DISEASES OF THE NASAL PASSAGES. 



at right angles, they are joined together, the upper end of the water 
tube being bent around at its upper extremity to meet the air cur- 
rent at a right angle. Subsequently these tubes were con- 
structed of hard-rubber and metal. The Sass tubes are now used 
practically to the exclusion of all other forms of atomizers, the air 
current being supplied as a rule by some form of pump or by water 
power. The latest and best atomizing outfit is shown in Fig. 17. It 
is made by Meyrowitz, of this city. 

Much ingenuity has been exercised in the construction of these 
various devices for atomizing fluids, and it has been a broadly pre'va- 




Fig. 17.— Sass" Spray Tube. 

lent impression that our success in the treatment of diseases of the 
upper air passages was largely dependent upon the elaborateness and 
perfection of our mechanical devices, especially those used for the 
production of sprays. Pressure of the air by which the fluids are 
atomized has also been thought of importance, the ground being taken 
that at a pressure of fifty or sixty pounds atomized fluids come more 
thoroughly in contact with the membrane lining the sinuous passages 
of the nose, and are so driven farther down into the bronchial tubes, 
the idea still being held that local applications constitute the essential 
element necessary for the cure of catarrhal diseases. This I believe 
to be an entire mistake. A catarrhal inflammation, as a rule, is not 
cured by the local application of astringent, alterative, stimulant, or 
other remedies, as will be more fully elaborated when we come to 
discuss the particular forms of inflammatory disease met with in the 
upper air tract. Local applications are undoubtedly useful, but I am 



INSTRUMENTAL METHODS OF TREATME1ST. 



21 



confident that those who place their main reliance on the use of sprays 
will find themselves disappointed in the results of treatment. All 
the apparatus necessary for the successful treatment of the ordinary 
cases which come under our observation may easily be carried 




Fig. 18.— The Ordinary Single-Bulb Hand-Ball Atomizer, fitted for Nasal Applications. 

in a small handbag. Kegarding then, an atomizing apparatus as a 
very great convenience, although not an absolute essential, it remains 
to suggest that perhaps the most convenient device is the ordinary 
Sass tube, constructed of met- 
al, with the air receiver and 
pump, preferably the water 
pump if one's office is sup- 
plied with the public water 
service; but this apparatus 
possesses no notable advant- 
ages over the simpler devices. 
In my own office work, after 
an experience of many years 
with various methods of at- 
omization, I have finally ar- 
rived at the conclusion that 
one's work can be quite as well 
performed, and even much in- 
convenience avoided, by using 
an ordinary single-bulb hand-ball atomizer. Of these perhaps the best 
is that shown in Fig. 18, which is constructed on the principle of Rich- 
ardson's atomizer. The device shown is fitted with a rounded bulb to 
adapt it for nasal application, although the same instrument is sup- 




Fig. 19.— Delano's Atomizer. 



22 



DISEASES OF THE NASAL PASSAGES. 



plied with both the laryngeal and post-nasal tip. This instrument is 
used, in the main, to apply cleansing and disinfecting lotions to the 
upper air passages, and delivers an abundant yet finely divided 
spray. For making applications of astringent, sedative, or other 
medicating solutions, preference should be given to some of the 
atomizers constructed on the Bergson principle. In Fig. 19 there is 
shown an atomizer, constructed on this principle, which is sold in the 
drug stores under the name of Delano's Atomizer. It delivers a very 
fine spray, the flow of which ceases immediately upon relaxing the 
pressure upon the bulbs ; it is therefore useful in making applications 
of cocaine, and for this purpose I regard it as of especial value. 



Inhalations. 

In 1864 Siegle put in practice the plan of using steam as the 
power by which fluids were atomized in the Bergson tubes. This, 
however, was not available for a direct application, but could only be 

used for inhalation,' and it is this prin- 
ciple which is made use of in the ordi- 
nary steam atomizers sold by the instru- 
ment makers at the present day. The 
principle on which they act is too well 
known to need remark. The drugs that 
can be used in the Siegle apparatus in- 
clude nearly the whole list of astrin- 
gents, alteratives, etc. In addition to 
these, there are certain drugs which con- 
tain principles which are volatilized 
when brought in contact with hot water 
at a temperature of not less than 150°. 
This list includes carbolic acid, creosote, 
camphor, oil of tar, tincture of benzoin, 
tincture of myrrh, oil of eucalyptus, 
terebene, pine-needle oil, ethereal tinc- 
ture of iodine, etc. A teaspoonful of any 
of the above, placed in an open-mouthed 
bottle or cup containing half a pint of 
water slightly below the boiling point, 
is placed beneath the mouth, and the fumes inhaled. In MacKenzie's 
inhalator, shown in Fig. 20, and instruments of that type, the volatile 
oils of the mdicament used are driven off more actively by means of 
a burning lamp placed beneath the reservoir or cup. 

There is a number of drugs which are volatile at the ordinary 




Fig. 20.— MacKenzie's Inhalator. 



INSTRUMENTAL METHODS OF TREATMENT. 



23 



temperature, the properties of which, as inhalants, possess a certain 
amount of value. The method by which these are used varies, but 
ordinarily is quite simple. A glass or vulcanite tube, into which has 
been inserted either cotton-wool or sponge, is the ordinary form. 
The absorbent material is charged with the drug which it is desired 
to use, and the little tube held either to the nostril or to the mouth, 
for the purpose of inhaling the fumes. This apparatus is oftentimes 
of no little use in the later stages of a winter cold or a bronchial 




Fig. 21.— Large Globe Inhaler for Inhaling Fluids Atomized by means of Compressed Air. 



attack, in stimulating the membrane to freer transpiration, and there- 
by promoting a resolution of the inflammatory process. 

In acute inflammations involving the upper air passages inhala- 
tions undoubtedly serve to relieve pain, and perhaps to mitigate the 
severity of the attack; they add much to comfort by relieving the 



24 DISEASES OF THE NASAL PASSAGES. 

irritability of the parts and lessening the severity and frequency of 
the cough. 

On the whole, however, inhalations are to be regarded largely as 
palliative measures. The elaborate apparatus for inhaling purposes 
may serve to produce a certain moral effect upon the patient, but I 
doubt if the action of the drug is not quite as efficacious in the sim- 
pler devices suggested above as in the more elaborate inhaler. The 
steam atomizer, while a somewhat entertaining toy, I have long 
discarded, because it not only accomplishes little good, but is capa- 
ble of doing mischief. Especially is this true in all forms of chronic 
disease of the air passages, as the hot steam so relaxes the parts as 
to counteract the benefit accomplished by the medicament. Indeed, 
none of the above methods of inhalation is to be used in chronic 
affections, unless, it may be the administration of the muriate of am- 
monia, which oftentimes serves to loosen the thick inspissated mucus 
of chronic bronchitis. 

Cold inhalations, by means of compressed air in the atomizer, 
have been, in the past few years, largely resorted to in the treatment 
of chronic affections of the upper air passages. They are admin- 
istered by directing the spray into one end of a large globe, the patient 
sitting in front of the opposite end, drawing the atomized fluids into 
the air passages. The principle of action is that the large particles 
of atomized fluids are arrested in the globe and fall to the sides, while 
the finer particles of the spray are carried to the air passages by the 
inspiratory act. The drugs used in this way embrace nearly the 
whole list of astringents, alteratives, etc., which are supposed to 
possess a certain amount of controlling influence on catarrhal proc- 
esses. This is undoubtedly a valuable method of applying astringent 
remedies directly to the upper air tract, and in those cases in which 
the inflammatory process has invaded the larger bronchial tubes its use 
is attended with better results than any other device which we possess. 
Certainly, it is far preferable to hot inhalations, either by means of 
the steam atomizer or the ordinary inhalator. In Fig. 21 is shown 
one of the more elaborate forms of the globe inhaler. 



CHAPTER III. 

MUCOUS MEMBRANES. 

All cavities inside the body, as the alimentary canal and the air 
passages, which open directly or indirectly on the surface are lined by 
soft and moist prolongations of the skin known as mucous membranes. 
These are covered by a layer of cells, known as the epithelium, which 
are in reality secreting glands to keep the membrane moist and soft. 
The secreting surface is greatly increased by a folding-in of the 
membrane upon itself, forming one or more flask-like cavities lined 
with epithelial cells and called follicular glands or racemose glands. 




Fig. 22.— Section of Mucous Membrane, drawn Diagrarnmatically. /, Submucous layer of connective 
tissue ; d and e, mucous membrane proper, containing blood-vessels, nerves, closed follicles, 
connective and elastic tissue fibres, and marked b}- villi ; c, epithelial layer ; b, simple follicle ; 
a, racemose gland. 



This, briefly and simply stated, is the design and function of a 
mucous membrane, a proper understanding of which is of the greatest 
importance to the proper appreciation of diseased conditions of the 
upper air tract. 

A mucous membrane is composed of three layers. 

First, a superficial layer composed of epithelial cells. 

Second, the mucosa proper, a layer composed of white fibrous and 
yellow connective elastic tissues, embracing within their meshes blood- 



26 DISEASES OF THE NASAL PASSAGES. 

vessels, smooth muscular fibres, different varieties of small glands, 
and presenting minute processes or villi. 

Third, a layer of loose connective tissue, the submucous cellular 
tissue (see Fig. 22), which is composed of a more or less loosely 
connected network of connective tissue, by which the mucous mem- 
brane is attached to the parts beneath, and, of course, allows of a 
very free play between the membrane and these parts. This fact 
becomes of extreme importance in connection with acute inflammatory 
affections of the membrane, as it admits of the effusion of serum into 
this layer where its attachment is very loose, as in the ary-epiglottic 
folds of the larynx, the posterior surface of the epiglottis, and the 
ventricular bands. 

Physiology. 

The function of a mucous membrane is to afford a soft, moist, 
and pliable lining to those cavities and passages of the body which 
communicate with the external world. It is lubricated by a clear 
fluid mucus, which is poured out upon it by the follicular and race- 
mose glands, whose ducts open upon its surface, and also by the 
epithelial cells which compose its superficial layer. 

Owing to the constant mechanical disturbance to which the 
membrane is subjected in mastication, speaking, etc., the cells of its 
superficial layer are being constantly detached and thrown off. In 
order to compensate for this loss, new cells are being continuously 
generated from below. 

Another physiological characteristic of mucous membranes is 
their permeability ; fluids penetrate them from without, are absorbed 
by the blood-vessels, and carried into the system. An exception to 
this rule is found in the fact that the virus of the snake does not per- 
meate mucous membranes, and is in no way absorbed by them, it 
being neecssary that it should meet with an abraded or cut surface 
in order to reach the blood-vessels and be taken up by them. The 
same is true of the syphilitic virus, which is inoculable only through 
an abrasion of the membrane. 

Inflammation of Mucous Membranes. 

Inflammation is that series of changes which takes place in any 
tissue as the result of irritation or of an injury, provided the injury 
is not of such a character as to completely destroy its vitality. This 
injury may be a direct irritation of the tissue by a mechanical or 
chemical agent, or the inflammation may be caused by some micro- 
organism, by syphilitic or tuberculous infection, or by indirect irri- 
tation as the result of exposure to cold. 



MUCOUS MEMBRANES. 27 

Through the researches and experiments of Cohnheim, Strieker, 
Burdon-Sanderson, and others, the nature of these changes is well 
known. 

The first effect of an irritation of the tissues is a dilatation of the 
arteries and veins. 

This enlargement of the vessels is attended with an acceleration 
in the flow of blood, dilatation of the capillaries, an exudation of white 
corpuscles and serum, constituting the well-known inflammatory effu- 
sion, and great alteration in the nutrition of the inflamed part. 

This, in brief, completes the picture of inflammation in general. 
Confining ourselves now to mucous membranes, we find certain pecu- 
liarities manifesting themselves in the processes. 

Inflammation of mucous membranes occurs in three different 
varieties : catarrhal, croupous, and diphtheritic. 

Catarrhal Inflammation. — This form is by far the most frequently 
met with. In its milder degrees it is characterized merely by an 
increased secretion of mucus, the membrane at the same time 
becoming swollen and reddened, as the result of the increased vascu- 
larity. As the inflammatory process becomes more severe, the 
vascular phenomena are more marked ; cell generation is more rapid, 
and leucocytes and pus corpuscles are poured out in great quantities 
in the increased exudate. The epithelium also loosens, and falls off 
more rapidly from the surface of the membrane, under the stimulus 
of the inflammatory process ; and as it progresses we have the mucous 
discharge gradually becoming a purulent one, from being so highly 
charged with these unripe cell elements, many of which are virtually 
pus cells. 

The process continuing, its activity, which so far has been largely 
confined to the superficial layer of the membrane, extends to the sub- 
epithelial layer or the mucous membrane proper, and the cell elements 
here take on renewed activity, and, being rapidly generated, they 
distend and infiltrate the parts. The membrane becomes thickened 
and swollen ; and there now may occur several secondary manifesta- 
tions of the inflammatory process. As the result of the loss of surface 
epithelium, the membrane may become denuded of its epithelial coat, 
and there may occur an abrasion, or so-called catarrhal ulcer. As 
the result of the distention and infiltration of the membrane proper, 
the glands may become so choked that their contents are imprisoned, 
and, as the result, there is formed a minute abscess, which, breaking 
and discharging, leaves a small ulcer. The acute process may sub- 
side, or it may lapse into the chronic state. In this the increased 
vascularity subsides to an extent, though the vessels remain perma- 
nently somewhat dilated. The cell production, however, goes on both 



28 DISEASES OF THE NASAL PASSAGES. 

in the epithelial layer and in the mucous membrane proper; and the 
increased secretion persists ; but all in a somewhat diminished degree. 

Chronic catarrh differs from acute catarrh in that in the formei 
the subepithelial layer of the membrane is much more involved. It 
is thickened and indurated by infiltration and also by a renewed 
activity in another elemental tissue of the membrane, viz., the 
connective tissue, which plays an important part in chronic inflam- 
mation. This tissue is developed now 7 by a slow process of prolifera- 
tion, and by its peculiar characteristics gives rise to those features 
of chronic catarrh wdiich render it extremely obstinate to manage. 

Having been once developed, it is probable that connective tissue 
is never absorbed or excreted as the other cell elements in catarrh ; 
but, becoming organized, it remains a permanent element in the 
membrane to deform, disorganize, and interfere with its proper 
function. As the result, then, of the new deposit, the normal 
thickness of the membrane is increased and its proper function 
impaired; as in the hypertrophied membrane of the nose, causing 
nasal stenosis, and thereby interfering with normal nasal breathing. 
Again the hypertrophied tissue presses upon the glands and follicles 
of the membrane in such a manner as to cause their atrophy, thus 
robbing the membrane of its proper supply of lubricating fluid, its 
mucus, and giving rise to the so-called dry catarrh. It may be 
deposited about the individual follicles or glands in such a manner as 
to press upon the outlet alone, thus closing them up, giving rise to 
small cysts, which, undergoing fatty degeneration, act as a source of 
renewed irritation and cause a more or less general glandular 
hypertrophy. 

In addition to this we notice a tendency in chronic processes to 
differentiation, by which in the one case the morbid process expends 
itself upon the epithelial and lymphoid structures, while in the other 
case it acts upon the connective-tissue elements of the membrane. 
Thus, in the former we may have a chronic catarrhal inflammation in 
which a rapid degeneration of epithelial cells occurs in such a manner 
as to increase to a very large degree not only their growth, but their 
loss from the surface, giving rise to a form of secretion from the mem- 
brane in which a large amount of mucus is thrown off, heavily sur- 
charged with unripe epithelial cells, causing muco-purulent discharge. 
Thus, in the purulent rhinitis of children, to be described later, the 
essential lesion consists in an intense activity in the epithelial struc- 
tures. Again, we may have the same activity in the lymphoid cells 
giving rise to a formative inflammation, as it were, in which the 
lymphoid cells are rapidly generated and remain a portion of the 
membrane, instead of being thrown off in the form of a purulent 



MUCOUS MEMBRANES. 29 

discharge. A lymphoid hypertrophy is the result of this form of 
catarrhal inflammation, such as is met with in adenoid disease of the 
vault of the pharynx, or hypertrophy of the faucial tonsil, or en- 
largement of the follicles of the lower pharynx. Activity of morbid 
processes confined largely to epithelial and lymphoid structures 
belongs essentially to the younger period of life, the diseases above 
referred to, it will be noticed, being all of them diseases of youth and 
childhood. The morbid activity in the connective-tissue structures, 
on the other hand, belongs essentially to later life ; hence a chronic 
inflammation of the mucous membrane, resulting in a connective- 
tissue hypertrophy, such as in hypertrophic rhinitis, is essentially a 
disease of adult life. This is due probably to the fact that the 
development and ripening, as it were, of a connective-tissue cell is a 
process of years, and that a true connective-tissue hypertrophy can 
exist only after a catarrhal inflammation has been in operation for a 
long period of time. 

Croupous Injktmmatwn. — This form of inflammation is of a higher 
grade, and of a more intense form than the catarrhal ; for, while it 
commences in the same manner, with distention of the blood-vessels, 
escape of liquor sanguinis and blood corpuscles, and proliferation of 
cells, it differs from it in the fact that the exuded liquor sanguinis 
contains a large amount of fibrin and albumin, which coagulates upon 
the surface of the membrane and forms a false membrane. This 
false membrane is of a more or less dense, firm character, and is 
composed of fibrin, inclosing a large number of epithelial cells in its 
meshes. At times it may be soft and almost granular in character, 
so much so that it may be easily removed with a soft brush, coming 
away in small broken particles. At other times it may be of so dense 
a character that after removal it can be torn only with considerable 
force. As a rule it can be easily removed, leaving the membrane 
beneath it in the main intact, merely deprived of some of its superficial 
epithelial cells. After removal, the same process may be renewed 
and a new membrane form, or the parts may be restored to their 
normal condition. 

The favorite site for this form of inflammation is in the upper 
air passages, the pharynx, tonsils, larynx, and trachea, though it may 
occur in the bronchi, intestinal canal, and other parts. 

"Why this form of inflammation occurs, it is impossible to state; 
but it is not improbable that it is due to some previously existing 
blood condition, which dominates the inflammatory process, and so 
far enriches the exuded liquor sanguinis with the fibrinous material 
that it coagulates on its exposure to the air, and so a false membrane 
is formed in place of the fluid catarrhal discharge. Further evidence 



30 DISEASES OF THE NASAL PASSAGES. 

that this form of inflammation is due to some previous condition 
in the blood is afforded by the fact that its onset and course are 
usually marked by a febrile movement, far more aggravated in 
character than we would expect to find as merely symptomatic of so 
limited an extent of local inflammation. The temperature in simple 
membranous sore throat, characterized by a croupous deposit on the 
tonsil, often ranges as high as 103°-104° F. 

Croupous inflammation may manifest itself in a fibrinous exudation 
on the surface of a mucous membrane, as in croupous laryngitis, or 
true croup, membranous sore throat, croupous rhinitis, etc. ; or the 
exudation may take place in the follicles of the membrane, giving 
rise to an acute follicular inflammation such as occurs in the affection 
generally known as acute follicular tonsillitis, which is a croupous 
inflammation of the tonsil, in which the exudation takes place in the 
crypts of the organ rather than upon its surface. 

Diphtheritic Inflammation. — This variety of inflammation, again, 
is characterized by the formation of a false membrane, and also 
^commences as a catarrhal inflammation, with its increased blood flow, 
cell proliferation, and exudation of liquor sanguinis, the exudation, as 
in the croupous form, consisting largely of fibrin and albumin ; but 
there is this difference, that while in the croupous form the exudation 
is poured out upon the surface of the mucous membrane, in the 
diphtheritic form it permeates and infiltrates its whole thickness, down 
to the submucous tissues. 

This exudation permeates the membrane so densely that in coag- 
ulating it completely destroys its vitality, and there results a dead 
membrane, involving the whole thickness of the mucous membrane. 
It is removed with considerable difficulty ; and in its removal, carry- 
ing with it the whole thickness of the membrane, leaves the parts 
beneath entirely denuded. The false membrane declares itself to the 
eye as a dead membrane, a genuinely necrosed or sloughing tissue, of 
a dark grayish color, resembling boiled macaroni; in contradistinc- 
tion from a croupous membrane, which is of a bluish, pearl-gray 
color, presenting no appearance of necrosis, but rather of an unmistak- 
ably living tissue. 

It should be understood, in regard to these terms, croupous and 
diphtheritic inflammation, that they refer only to forms of inflammation 
to which mucous membranes are subject, and not to the specific 
diseases which are spoken of under the names croup and diphtheria ; 
as, for instance, membranous croup is generally understood to be a 
croupous inflammation of the mucous lining of the larynx, although 
a better classification would suggest the more expressive and correct 
name of croupous laryngitis ; and also of diphtheria — it is a blood 



MUCOUS MEMBRANES. 31 

disease, characterized by a local manifestation in the throat, consist- 
ing of an acute inflammation of the mucous membrane, which assumes 
the diphtheritic form; so that when we speak of croupous and 
diphtheritic inflammation, we simply define the form which the 
inflammatory process assumes. 

In regard to catarrhal inflammation, or, as it is generally called, 
catarrh, the same may be said ; properly speaking, it means that form 
of inflammation of a mucous membrane which is characterized by an 
excessive discharge of mucus or muco-pus ; but a better usage in the 
direction of an exact classification would suggest that the local 
designation should be prefixed, as nasal, laryngeal, bronchial 
catarrh, etc. 



CHAPTER IV. 

TAKING COLD. 

If we ask ourselves what special influences produce the morbid 
changes of the common and familiar phenomenon which we call 
taking cold, or what is the true relation between the recognized causes 
and observed effect, we find it somewhat difficult to give a correct 
answer to the question. 

Among the numerous theories advanced may be mentioned that 
of Eosenthal, who asserts that the immediate effect of cold, acting on 
the surface of the body, is to excite contraction in the peripheral 
vessels, by which the blood is driven from the surface in upon the 
internal organs, and acts there as an irritant, exciting inflammation. 
This view of the matter scarcely explains the action of cold when 
membranes near the surface are involved, as in coryza or conjuncti- 
vitis. Schenk 1 found that warmth excites a movement in micro- 
organisms toward a centre of warmth. He arranges ordinary colds 
into two groups — those due to bacterial infection, and those that are 
not. In the former, there is a period of incubation; in the latter the 
disease follows quickly after exposure. When a person exposes 
himself to cold, the bacteria tend toward his body as a focus of 
warmth, where under some possible conditions they seem to pene- 
trate the mucous membranes or skin. 

Seitz's theory is that disorders resulting from catching cold are 
due to the removal of heat to an unusual extent from the external or 
internal surface of the body ; that this causes some functional dis- 
turbance, which in its turn gives rise to certain morbid processes in 
some portion of the body, far removed from the part immediately af- 
fected by the col$. That the morbid changes are not due to the im- 
mediate or direct effect of this exposure is evident from the fact that, 
as a rule, a certain length of time elapses before these changes set in. 

The theory of Seitz, it seems to me, is not complete. The true 
action of cold upon the body, in producing morbid conditions, is 
probably on those nutritive changes which are constantly going on, 

1 Centralblatt fiir Bacteriologie, July 18th, 1893. 



TAKING COLD. 33 

and by which the animal heat is developed. Any marked deviation 
in the production of heat in the body from the normal standard, as 
the result of extraneous influences, results in morbid changes. In the 
ordinary phenomena of "taking cold," we have the results of a low 
temperature acting on the heat-producing processes, but in an indirect 
manner. The direct action of the cold is, as a rule, upon the surface 
of the body, but the resultant morbid condition is upon some organ 
remote from the exposed part. In both cases, however, the cause 
and the effect are the same, and the connection between the exposure 
and the resultant inflammatory condition is the disturbance of those 
nutritive changes in the tissues which result in the production of 
auimal heat. The nutritive processes going on in the whole economy 
are governed by* the central nervous system, and, furthermore, a 
certain amount of nervous force is expended in the regulation of these 
nutritive processes. If, as the result of exposure to cold, these 
nutritive changes are arrested in a certain portion of the body, the 
same nervous force being sent out from the central system, it will be 
understood how this local arrest of the nutritive process in one por- 
tion would be attended with a certain amount of increased nutritive 
activity in another portion ; the activity of the nerve centres going on 
as before. Now, increased nutritive activity constitutes inflammation, 
and this inflammation locates itself at the point of least resistance, 
viz., as a rule, at some point in the economy where a mild chronic 
inflammatory process is going on, which is lighted up into an acute 
process as the result of a cold. A cold then is contracted from an 
exposure not of the whole, but of a part of the body, as the result of 
which the physiological processes of heat production in that part 
alone are disturbed, giving rise to increased nutritive activity or 
inflammation in some organ far removed perhaps from the site of the 
primary exposure. As a matter of clinical observation, we know that 
colds occur during the spring and fall months, seasons which are 
characterized by moderately low temperature, but with notable 
dampness of the atmosphere together with considerable atmospheric 
motion, or high winds. Hence we recognize that there are three 
factors usually necessary for the production of "a cold" — low temper- 
ature, air in motion, and moisture. It is also necessary, as a rule, 
that one or more of these factors should act for a somewhat prolonged 
duration of time. The momentary action of an intense cold, or 
draught, or moist atmosphere, does not usually result in any morbid 
changes, but it is only after a somewhat prolonged exposure of the 
body that the familiar phenomena of a cold ensue. Among the most 
familiar causes of taking cold may be enumerated sitting in a draught 
wearing insufficient clothing, insufficiently protected feet, going from 
3 



34 DISEASES OF THE NASAL PASSAGES. 

a warm room to a cold room, slight exposure while perspiring, etc. 
Wearing thin-soled shoes, or insufficiently protected feet, is a very 
prolific source of trouble : as the loss of heat in this manner is far 
greater than is usually recognized. Especially is this the case if the 
soles of the shoes are damp, as the radiation then takes place much 
more rapidly. 

Again, when the body is perspiring, the loss of heat is going on 
with considerable activity ; and we find that even a slight exposure is 
liable to result in far more serious disturbance than would occur from 
the same exposure were the body not in an overheated condition. 
There should, however, be borne in mind this difference : if the per- 
spiration is the result of violent exercise, all the nutritive processes 
are stimulated to an abnormal activity, animal heat is being generated 
rapidly, and the perspiration necessarily sets in as a conservative 
measure, to prevent too great accumulation of heat in the system, but 
still as the direct consequence of the violent exercise. If now in this 
condition the body is exposed to the influence of cold, and the per- 
spiration suddenly checked, very serious consequences may ensue. 
But if, on the other hand, a copious perspiration is brought on by 
artificial means, while the body is in a state of quiescence, as in the 
hot room of the Turkish bath, the heat source is from without, the 
heat-producing forces of the system are not disturbed, and the cold 
plunge, while of course it suddenly checks the perspiration, does not, 
as a rule, give rise to any untoward consequence. Moreover, the 
exposure by the cold plunge is only temporary and of short duration, 
and by the subsequent manipulation any serious loss of heat which 
may have resulted is speedily and completely restored. 

A swimmer will remain in water at a temperature twenty or thirty 
degrees below that of the body for a somewhat prolonged period of 
time ; but while in the water he is in a state of constant and laborious 
activity, thereby setting in play those processes by which animal heat 
is generated. But even with this constant activity, if the bath be- 
comes too prolonged, there comes a time when the body is unequal 
to the task of supplying sufficient animal heat to make up for the 
loss, and the bather succumbs to the direct influence of this tremen- 
dous drain upon the system. Here the result is not an inflammatory 
attack such as usually accompanies an exposure to cold, but on the 
contrary, there is usually produced great prostration, violent cramps, 
weakened circulation, intense venous congestion, and in fact, 
the whole system is robbed of its normal heat, which loss tends to 
retard all healthy functional activity in the body ; whereas the results 
of an exposure to cold are due to a localized arrest of heat produc- 
tion, and a disturbance of the balance, as it were, by which nutritive 



TAKING COLD. 35 

activity goes on in the system. As was said before, the loss of 
animal heat does not directly produce these morbid changes, but 
creates or gives rise to certain functional disturbances, with the 
nature of which we are not entirely acquainted, and these give rise, 
after a certain interval of time, to the morbid changes which we call 
taking cold. This interval may be short, lasting perhaps but a few 
hours, as is usually the case in slighter disorders, or it may be pro- 
longed one or two days, or even more. In this case, as a rule, the 
resultant disorders are of a more serious character. There is usually 
attendant upon taking cold fever of a more or less marked character. 
That this fever is not symptomatic, but an essential fever, is shown 
by the fact that it stands in no constant relation to the morbid changes 
which result, as in even slight disorders we may have the febrile 
motion more marked than the fever which accompanies the more 
aggravated forms of inflammatory troubles which may rise from a 
cold. Moreover, the fever usually set in immediately after exposure, 
and when the later morbid changes appear no increase of fever, as a 
rule, is detected. The local disorders resulting from an exposure to 
cold are manifested in any part of the body. Owing to their exposed 
situation, being the first to receive the current of inspired air, with 
its impurities, or whatever of irritating qualities it may possess, the 
upper air passages are perhaps more subject to inflammation than 
any other portions of the body, and, once having become the seat of 
morbid changes, there is always a liability to a recurrence of the 
attack from a slighter exciting cause than that which gave rise to the 
first attack. 

As these attacks recur with increased frequency and gravity, we 
find that the morbid process localizes itself farther down, and nearer 
to the vital centres, and finally this liability, so called, to take cold, 
gives rise to a bronchitis, or some still graver affection, which, fixing 
itself upon the lungs, ma}' prove far less amenable to treatment than 
the simple attacks which preceded it, or even lead to the development 
of those still graver forms of pulmonary disease. 

The question is often put to the physician, whether a catarrh will 
lead to the eventual development of lung disorders ; and it seems to 
me that the answer should be that it may, and that it often does, in 
the manner above noticed. 

This may not occur by absolute extension of the inflammatory 
process, but there can be no question that an individual suffering 
from a chronic laryngeal catarrh is far more liable to an attack of 
tracheitis, and that one suffering from a tracheitis is far more suscep- 
tible to a bronchitis than one in whom there exists no catarrhal 
inflammation; and so on, down to the deeper lung tissues. 



36 DISEASES OF THE NASAL PASSAGES. 

As regards this so-called liability to take cold, it should be 
understood that this, in a large majority of cases, and probably in 
every case, is due to an existing chronic catarrhal inflammation, of 
perhaps so mild a type as to give rise to but very trival symptoms, 
or even pass unnoticed; but still, an existing catarrh, the result 
probably of a neglected cold; and the renewed attacks to which the 
individual becomes so liable consist in a lighting up of the old 
trouble. The existing catarrh finally becomes established as a 
chronic process. 

Prevention of a Cold. — The conditions which give rise to a cold 
should be avoided, especially by those possessing hereditary ten- 
dencies or weaknesses and by those who are liable to take cold. These 
directions, of course, are more important in the months of the year 
when we have to the greatest extent the prevalence of a low temperature, 
moisture, and air in motion ; these we find in the spring and fall. 
Perhaps the most important direction that can be given in regard to 
preventing colds is as to the proper regulation of the clothing. The 
body should be sufficiently clothed for warmth and comfort, no less 
and no more. If too little clothing is worn, there will necessarily 
result a loss of animal heat. If too much is worn, the body becomes 
overheated, and perspiration necessarily ensues to reduce the tem- 
perature and restore the proper equilibrium, and consequently, as we 
have before seen, a condition arises in which the body is extremely 
sensitive, and in which it is especially liable to succumb to the 
influence of cold or moisture. This rule in regard to clothing the 
body applies to all parts of it. The mistake should always be avoided 
of coddling any portion or of leaving any portion insufficiently pro- 
tected. A very frequent and common error is fallen into by many, of 
crowding on too much clothing upon those portions of the body which 
they suppose to be subject to some special weakness; as, for instance, 
many people, supposing themselves to have weak lungs or throats, 
fall into the error of piling wrap upon wrap, muffler upon muffler, 
around their necks and about their chests, thereby encouraging the 
very condition which they fear, and incurring the risk they desire to 
avoid; for the excessive muffling of the parts necessarily leads to 
perspiration, and consequently the danger of its being suddenly 
checked upon the removal of the wraps. As a rule, when a sore throat 
comes on, the very first remedy which is adopted is to tie a piece of 
red flannel about the neck. The only advantage of this procedure 
lies in a certain amount of counter-irritation, due to the harsh fibre 
of the flannel rubbing against the skin. Aside from this, there is no 
possible good to be accomplished. It is put on for a protection ; it 



TAKING COLD. 37 

simply renders the neck and throat more sensitive, and entails a 
greater liability to take another cold. Of course, what is said about 
the neck may be said about any other portion of the body. Perhaps 
the very worst place in which to wear the so-called chest protectors 
sold in the drug stores, is on the chest. The chest is infinitely bet- 
ter protected, in one liable to bronchial attacks, by an extra sole worn 
on the boot than by a felt pad worn across the chest. The whole 
theory of clothing should be based on the idea that exposure to cold 
results in an interference with nutrition in some part of the body. 
Therefore, to prevent taking cold, the clothing should be uniformly 
distributed over the body, with simply enough of it for comfort, and 
absolutely no more. 

The selection of the proper fabric to be worn next the skin is too 
often dictated by a consideration of luxury, rather than of health. The 
most important function that goes on in the skin, is that by which 
the bod} T is kept at an equable temperature, by means of perspiration. 
Theoretically, this is accomplished by means of an insensible per- 
spiration, and practically too, except under extraordinary circum- 
stances, when the perspiration becomes profuse. Now this function 
of perspiration, or heat radiation, takes place best when the fabric 
next the skin is a thoroughly porous one. We have no fabric com- 
parable to pure wool in this respect. Silk is very objectionable, in 
that cutaneous transpiration is interfered with. The same is true 
of cotton and linen. I regard the heat-conducting properties of these 
different materials as a matter of little moment, compared with the 
greater importance of wearing next to the skin a thoroughly porous 
and elastic fabric. 

It is the habit to change the thickness of the underwear twice and 
sometimes even three times during the year, through the varying 
degrees of cold and heat. This plan is not wise in all cases, and is 
even a source of mischief. We practically live, during a large portion 
of our time, in much the same temperature, summer and winter, or, 
rather, we endeavor to keep our houses during winter at a tempera- 
ture of about 70° F. I doubt the wisdom of wearing very heavy under- 
wear in rooms so heated, as the necessary consequence is a more or 
less profuse perspiration. A better plan is to wear the same thick- 
ness of underwear throughout the year, while the protection from 
the extreme cold of winter is supplied by a change in the outer 
garments. 

As before stated, excessive covering should be avoided under all 
circumstances. This perhaps is a greater error than insufficient 
protection, although the latter is undoubtedly a frequent source of 
trouble, especially when the feet are concerned, for, coming in contact, 



38 DISEASES OF THE NASAL PASSAGES. 

as they do, with cold floors and pavements, and a wet or damp 
ground, the loss of heat from the general system by reason of such con- 
tact is necessarily rapid, unless the foot is thoroughly well protected by 
a thick, dry sole to the boot. In our climate, with its sudden and 
marked changes of temperature, the proper regulation of the clothing 
becomes a matter of considerable importance, and perhaps of no little 
difficulty. The hands and face are rarely covered, as a rule, or 
protected, and yet we never take cold from their exposure. The 
deduction is obvious : if certain parts of the body may be exposed 
with impunity, the converse conclusion is suggested, that by keeping 
our bodies too warmly clad we have thereby engendered a necessity, 
which possibly might have been avoided with benefit to the health 
and vigor of the system. The rule may be safely laid down, that, in 
clothing the body, the trunk and limbs should be made simply 
comfortable, but never wrapped to the extent of inducing perspiration 
by the amount of clothing. Hats and caps, being a necessity of 
modern life, should be light, well-ventilated, and designed to retain 
as little heat as possible ; they should not be too heavy, nor press with 
too much weight upon the head ; the crown should be perforated, to 
allow of as free circulation of air as possible between the top of the 
head and crown of the hat, and should be constructed of such material 
as will allow the escape of heat. 

The hair, the natural covering of the head, should not be cut 
when the removal of so much protection of the head is liable to result 
in catching cold. 

In short, the body in all its parts should be made comfortable. It 
should not be so clothed as to cause perspiration, nor that chilling 
can occur. Very much harm is done by the habit of wearing heavy 
clothing and sitting in overheated rooms. Those who allow them- 
selves to grow into the habit, by which they are comfortable only in 
a room at 80° F., are simply making hot-house plants of themselves, 
and are engendering a condition of the system which renders its 
resisting power very feeble. It is purely a habit, and one easily 
overcome, not only without risk but with undoubted benefit to the 
individual, in the increased vigor of body which will result. 

In our variable climate, where the daily changes are oftentimes so 
great, it is a mistake to suppose that we can so regulate our clothing 
as to protect ourselves from the results of these great changes. We 
protect ourselves from absolute cold by wearing clothing, but 
not from taking cold. "We protect ourselves from taking cold 
by so regulating our habits of life as regards clothing, etc., 
that we expose ourselves to these changes with impunity. In 
other words, we inure ourselves to the climate. Perhaps we have 



TAKING COLD. 39 

no better way of maintaining the functions at the highest point of 
healthy activity than in the daily use of the cold bath. For those 
whose physique is equal to it the daily use of the cold plunge or 
shower bath is to be recommended, as the best protection possible 
against taking cold. If this is not well borne, it is clearly indicated 
by the feeling of lassitude and the chilly sensations which will follow 
the use of the bath; the contrary being indicated by the sense of 
warmth and general invigoration which attends its use. If the plunge 
or shower is not tolerated, the cold sponge, either of the whole body 
or to the waist, is to be commended. The time at which the bath 
should be used is preferably in the morning, in that not only the 
night sleep is a better preparation for it, but also the exhilaration 
and vigor which follow it are an excellent preparation for the labor of 
the day. The Turkish bath, which has become so deservedly popular 
in our da}', while undoubtedly a luxury, is to be commended with a 
certain amount of reserve as a preventive, or in the treatment of a 
cold. 

Treatment of a Cold. — It is much to be deprecated, that, as a 
rule, an ordinary cold is allowed to take its own course without 
treatment. If a part has once become inflamed and is permitted to 
undergo resolution without interference, it is left in a weakened con- 
dition, which invites renewed attacks from a slight cause ; for when 
the acute inflammatory process subsides, complete resolution does not 
take place, but there is left a 'morbid condition, very mild in character 
perhaps, but nevertheless one of chronic inflammation. This may be 
so slight as to be scarcely noticeable by the patient, and yet it is this 
condition which takes on a renewed inflammation from a very slight 
provoking cause, which oftentimes the patient would escape did it 
not exist. The ordinary plan of treatment of a cold is so simple, and 
involves so little trouble, that it is the duty of the physician to urge 
that all cases, however simple, should be subjected to it. 

Remembering the causes, as laid down above, which operate in 
the production of a cold, the first indication for treatment will be to 
supply as promptly as possible the deficiency caused by this loss of 
body heat. If this can be done in the early stages, when the sec- 
ondary inflammatory process has not progressed, or, better still, before 
it has set in, viz. , during the preliminary febrile stage, the further 
progress of the disorder may be promptly arrested; this constitutes 
what we generally call the abortive plan of treatment. The plan 
consists, in short, of producing copious perspiration; this perspira- 
tion, be it remembered, however, is not primarily the object it is de- 
sired to attain, but it is simply the evidence that that object has been 
attained. The condition to be corrected is loss of body heat; the 



40 DISEASES OF THE NASAL PASSAGES. 

measures resorted to for this are measures which, have a tendency to 
increase body heat. The evidence that this has been accomplished, 
viz., the restoration of this heat, or even more, that an excessive heat 
has been produced, is manifested by the perspiration. If this so- 
called sweating can be brought on in the early stage, it serves the 
purpose of arresting the future progress of the trouble and putting an 
end to the inflammatory process. If it can be brought about early in 
the progress of the inflammatory stage, the gravity of the attack can 
be very materially lessened ; hence, the earlier this abortive treatment 
is resorted to, the better the result. The means of accomplishing this 
is by simple remedies, familiar to all. 

A decoction of hot tea, taken at bedtime, with the addition of a 
foot-bath and a moderate dose of Dover's powder, is all that is nec- 
essary ; after which the body should be warmly covered in bed, and 
extreme care exercised to prevent any exposure while the perspiration 
is going on. If the constitutional symptoms assume a graver form, 
that is, if the fever seems excessive, and the effect on the general 
system marked, much benefit will be gained by the administration of 
ten grains of quinine, in connection with the diaphoresis. It is 
generally asserted that following a copious perspiration there is 
danger of contracting additional cold, on leaving the bed in the 
morning. This probably is a mistake, although the simple precaution 
should always be taken of allowing the body to cool off gradually 
before rising, by removing a portion at a time of the bed covering, 
and also remaining indoors for a few hours after dressing. If, as 
the result of this treatment, all symptoms disappear, little else is 
needed, except the exercise of ordinary precaution. 

If, however, the inflammatory stage has set in, and the result of 
the sweat has been simply to modify and not to remove it, other 
measures, directed to the special locality of the inflammation, should 
be resorted to. The remedies indicated will be referred to when we 
come to treat of special diseases. Confinement to the house should 
be urged in all cases, as of equal if not of greater importance than 
therapeutic measures, especially if the inflammatory condition shows 
any possible grave tendencies. 



CHAPTER V. 

THE ANATOMY OF THE NOSE. 

The External Nose. 

The external nose, the most prominent feature of the face, is com- 
posed of a bony and cartilaginous framework, covered with muscular 
tissue and integument. The bony portion of the framework is com- 
posed of the nasal bones and the nasal processes of the superior 
maxillse. 

The Nasal Cartilages. — The cartilages are five in number, the two 
upper and two lower lateral cartilages, often called the alar cartilages, 
and a single cartilage in the median line, the triangular cartilage of 
the septum. At the junction of the lateral cartilages with the bony 
framework, two or three sesamoid or accessory cartilages are ordi- 
narily found. These cartilages are joined to each other and to the 
bony framework, by articulations which allow of a certain amount of 
motion. 

The Nasal Foss^:. 

The nasal passages are composed of two wedge-shaped cavities, 
extending from the nostrils in front to the posterior nares, by which 
they communicate with the upper pharynx. The roof of these cavities 
is narrow, and somewhat arched from before backward, and is com- 
posed of the nasal bones in front, the body of the sphenoid behind, 
and the cribriform plate of the ethmoid between them. The floor 
is formed by the palatine processes of the superior maxillae and the 
palate bones. The two cavities are separated from each other in the 
median line by the septum, which is composed of the perpendicular 
plate of the ethmoid above, and the vomer below. Up to the seventh 
year of life the septum lies in the median line, but after this time 
there is usually some slight deviation to one or the other side, not, 
however, enough to encroach in any degree upon the breathing-space. 
The outer wall of each cavity is formed by the superior maxillary, 
lachrymal, palate, and sphenoid bones, and is traversed antero-pos- 
teriorly by three scroll-shaped bones, commonly called the turbinated. 



42 



DISEASES OF THE NASAL PASSAGES. 



The lower turbinated bone is a very thin lamella of osseous tissue, 
curled upon itself, which is attached to a slight horizontal ridge 
presenting on the outer wall of the cavity. 

The middle turbinated bone belongs really to the ethmoid, and 
hence it is sometimes called the lower ethmoidal turbinated. It 
consists of a broad, thin plate of bone, passes downward, and is 
curled upon itself in the same manner as the lower turbinated. 

The superior turbinated is small. In its posterior portion it is 




Fig. 23.— Outer Wall of Left Nasal Cavity, the Inferior and Middle Turbinated Bones having been 
Removed. (Zuckerkandl.) A, Roof of nose ; B, floor of nose ; 6, hiatus semilunaris and os- 
tium maxillare ; c, portion of outer wall of nose encroaching upon cavity of antrum ; d, open- 
ing of lachrymal canal ; e, bulla ethmoidalis ; g, small canal between anterior insertion of 
middle turbinated and the ethmoidal cells ; i, ostium frontale ; k, furrow forming boundary 
between the nasal and naso-pharyngeal cavities. 



entirely distinct from the middle turbinated bone, but anteriorly is 
merged with it. 

These turbinated bones are nearly parallel with one another, and 
divide each cavity into three passages — the lower, the middle, and the 
superior meatus. 

In the anterior third of the lower meatus, below the lower turbi- 
nated bone, is found the opening of the lachrymal duct. 

Beneath the middle turbinated is to be found the opening into 



THE ANATOMY OF THE NOSE. 43 

the antrum of Highmore. It is in the middle meatus that we find the 
openings into the maxillary and accessory sinuses, as well as into the 
anterior ethmoidal cells. 

Above the middle turbinated bone we find the superior meatus, 
of chief interest from the fact that into it open the posterior ethmoidal 
cells and the sphenoidal sinus, by means of the recessus ethmoidalis. 
This small opening lies in the very posterior part of the superior 
meatus, and when a fourth turbinated bone is present is situated 
immediately behind this. 

The Accessoky Sinuses. 

Communicating with each nasal fossa are four cavities, usually 
designated as the accessory sinuses. These are the maxillary, fron- 
tal, sphenoidal, and ethmoidal sinuses. 

The Antrum. — The maxillary sinus, or antrum of Highmore, the 
largest of these accessory cavities, is a pyramidal-shaped cavity, 
hollowed out of the body of the superior maxilla and varying in size 
in different persons. 

The Frontal Sinuses. — The frontal sinuses are two triangular- 
shaped cavities, which lie between the two tables of the frontal bone, 
the floor being formed by the roof of the orbit. They are absent in 
childhood, but become developed in adult life. They communicate 
with the nares through the infundibulum, a rounded opening in the 
anterior extremity of the hiatus semilunaris. Occasionally these 
sinuses are entirely absent. As a rule, they are separated from one 
another, but more frequently than in any other of the accessory 
sinuses a normal opening exists from one side to the other, and in 
still rarer instances an opening is found between the frontal sinus 
and the orbit, or between this cavity and ethmoidal sinuses. 

The Sphenoidal Sinuses. — The sphenoidal sinuses are two compara- 
tively large rounded cavities hollowed out of the body of the sphenoid 
bone, and are separated from each other by a thin lamella of bone or 
septum. They communicate with the nares by a small opening into 
the superior meatus. These sinuses are also occasionally absent, 
their places being filled by solid bone. Zuckerkandl has also found 
in rare instances, instead of two lateral sinuses, a horizontal plate 
dividing the cavity, in which case the upper cavity opened directly 
into the ethmoidal cells, the lower opening into the nasal fossa. A 
still rarer anomaly is that in which the anterior wall is entirely 
wanting, the cells opening directly into the ethmoidal sinuses. 

The Ethmoidal Sinuses. — The ethmoidal sinuses differ from all the 
other accessory cavities, in that, instead of being large hollow 



44 DISEASES OF THE NASAL PASSAGES. 

cavities, they are composed of a large number of small cells, separated 
from each other by thin lamellae of bone. They divide themselves 
naturally into two groups, the anterior and the posterior ethmoidal 
cells ; the anterior opening into the nasal cavity in the hiatus semi- 
lunaris by means of small openings called the ostia ethmoidalia, 
while the posterior group opens into the superior meatus. The 
ethmoidal cells are less definite in their boundaries than any of the 
others, as they may extend either into the sphenoidal cells posteriorly, 
or into the frontal sinuses. Again, we may have an abnormal open- 
ing into the orbital cavity, in consequence of which emphysema of 
the orbit may occur. 

The mucous membrane lining these sinuses is continuous with, 
and differs in no marked degree from, that lining the nasal cavities, 
unless we note that in the maxillary sinuses the membrane is thrown 
into folds by a sort of redundancy of tissue, as it were. 

The Mucous Membeane. 

The mucous membrane lining the nasal cavities is continuous with 
that of the pharynx, and extends into the Eustachian tubes and the 
accessory cavities. Its superficial layer is composed of columnar 
epithelium in the upper portion of the cavities, as low as the middle 
turbinated bones, and the upper third of the septum. The remain- 
ing portion of the lining membrane is endowed with columnar ciliated 
epithelium, although, according to some writers, the epithelium is 
also ciliated in some portions of the olfactory tract. This fact becomes 
of some importance in connection with those diseases of the cavity 
which act to destroy or impair the vibratory motion of the ciliae, as 
this function undoubtedly has an influence in promoting the move- 
ment of the mucus and facilitating its discharge; hence, therefore, 
its abolition increases the tendency to an accumulation of the dis- 
charges in diseased conditions. The muciparous glands are usually 
of the tubular variety. 

In addition to the muciparous glands, we find in the olfactory 
region (that part above the middle turbinated bones) tubular glands 
which, from the name of their discoverer, are called Bowman's glands. 

In that portion of the nose immediately within the nostril, called 
the vestibule, we find the mucous membrane largely endowed with 
vascular papillae and covered with squamous epithelium, in fact so 
closely resembling the integument that, as Moldenhauer observes, it 
is really to be regarded as a process of the skin. 

We find, also, in this locality a number of stiff hairs, termed 
vibrissas, whose object is merely to purify the inspired air. 



THE ANATOMY OF THE NOSE. 



45 



The Nerves. — The innervation of the nasal mucous membrane has 
its source in the olfactory nerve, together with the nasal branch of 
the ophthalmic, the superior maxillary branches of the trigeminus, 
and filaments from Meckel's ganglion. The olfacory nerve supplies 
the nasal cavity with the special sense of smell. This nerve arises by 
three roots, which unite in a flat band which passes forward along 
the base of the brain until it reaches the upper surface of the ethmoid 
plate. Here it is expanded into the olfactory bulb, from which fifteen 
to eighteen branches are given off on either side and are distributed to 
the mucous membrane covering the superior and middle turbinated 
bones and the upper third of the septum. They termi- 
nate in minute thread-like filaments, which pass to 
the surface of the membrane, between the epithelial 
cells. In the continuity of this filament, before it 
reaches the surface, there is found a minute bulb-like 
expansion, the olfactory cell, as shown in Fig. 24. 

The nasal nerve, arising from the ophthalmic divi- 
sion of the trigeminus, on entering the nose divides 
into two branches : an internal, which supplies the 
mucous membrane near the anterior part of the sep- 
tum, and an external, which, descending in a groove 
on the inner surface of the nasal bone, and sending 
a few filaments to the mucous membrane as far down 
as the lower turbinated, becomes cutaneous at the 
junction of the upper lateral cartilage with the nasal 
bone, and furnishes cutaneous sensibility to the tip of 
the nose. 

The branches of the anterior dental nerve supply- 
ing the mucous membrane are distributed to the in- 
ferior meatus and inferior turbinated bone. 

The branches from Meckel's ganglion enter the nasal cavity 
through the spheno-palatine foramen. One of these branches forms a 
communication with the anterior dental nerve within the antrum, 
giving rise to the so-called ganglion of Bochdelek. The naso-palatine 
branch passes forward across the roof of the nose, and runs obliquely 
downward and forward, along the lower part of the septum, and 
pierces the hard palate through the anterior palatine foramen, join- 
ing the anterior palatine nerve. 

We thus find the mucous membrane endowed with general sensa- 
tion through the same nerve trunk as that by which vasomotor 
control is exercised, namely through the fifth nerve. This peculiar 
anatomical characteristic in the nasal mucous membrane has been 
very largely made use of to substantiate the various theories as 




Fig. 24.— The Olfac- 
tory Cells in Man. 
(Max Schultze.) 



46 DISEASES OF THE NASAL PASSAGES. 

regards the causation of hay fever, asthma, and other so-called reflex 
neuroses. I question if these theories rest on any well-substantiated 
grounds as yet. 

Blood- Vessels. — The vascular supply of the nasal fossae is derived 
from the anterior and posterior ethmoidal arteries, branches of the 
ophthalmic, which supply the ethmoidal cells, frontal sinuses, and 
roof of the nose; the spheno-palatine, from the internal maxillary 
artery, distributed to the mucous membrane covering the spongy 
bones and the septum; and the alveolar branch, from the internal 
maxillary artery, supplying the lining membrane of the antrum. 

The Tukbinated Bodies. 

In addition, however, to the parts already described, there are 
found beneath the surface of the mucous membrane, on the faces of 
the lower and middle turbinated bones, large plexuses of blood- 
vessels, the turbinated bodies, which have figured so extensively in 
our literature of the last fifteen years, and have been the subject of 
so much speculation and discussion. This mass of blood-vessels was 
recognized by anatomists in the last century, but in a vague and 
somewhat indefinite way. 

Zuckerkandl describes the mucous membrane covering the tur- 
binated bones as consisting of connective tissue, the upper surface 
covered with flat epithelium, the deep layer forming the periosteum of 
the turbinated bones. Between these two layers we have abundant 
lymph tissue, and possibly lymph glands, although these have not 
been definitely made out. The tissue covering the turbinated bones is 
studded here and there with tubular mucous glands, many of which 
extend completely through to the periosteum. Within this lymphoid 
structure we have abundant venous plexuses to which he gives the 
the name " Schwellkorper" (swell bodies). About the venous plexuses 
the unstriped muscular fibre is abundantly distributed. The definite 
localization of the venous plexuses serves to distinguish this tissue 
from true erectile tissue, such as is found in the corpora cavernosa of 
the penis. The arterial supply is derived from the spheno-palatine 
artery. The capillaries are divided into three sets, one set being dis- 
tributed to the periosteum, the second to the glands, the third to the 
surface. The capillaries distributed to the surface form loops which 
empty into the veins, together with the superficial gland capillaries. 
The deeper gland capillaries, and these distributed to the perios- 
teum, pass into the veins, forming the so-called Schwellkorper, and 
the blood is then conveyed by venous channels in the periosteal sur- 
face of the membrane to five distinct plexuses, one going to the veins 



THE ANATOMY OF THE NOSE. 



47 



of the face, the second to the veins of the cranium, the third to the 
orbit, the fourth to the soft palate, and the fifth to the hard palate. 
These Schwellkorper are distributed according to Bresgen as follows : 
one over the lower turbinated body, one along the border of the 
middle turbinated body, and one at the posterior extremity of each 
of the turbinated bodies. 




Fig. 25.— Section of the Cavernous or Erectile Tissue of the Middle and Lower Turbinated Bones, 
Inflated and Dried. X 2 diameters. (Bigelow .) 



We find, therefore, the nasal cavity containing this most intricate 
and delicate apparatus, which is designed to subserve the function of 
serous exudation. The special method by which this serous transu- 
dation takes place we are scarcely ready to describe. Chatellier sug- 
gests that certain minute canals which run at right angles to the mu- 
cous membrane, penetrating to the lymph channels, serve the purpose 
of serous channels. The question arises, whether Chatellier's canals 
may not be the tubular mucous glands of Zuckerkandl. 



CHAPTER VI. 

THE PHYSIOLOGY OF THE NOSE. 

The nose performs a threefold function in the economy. It is the 
organ which presides over the sense of smell; it gives a certain 
character and resonance to the voice ; and it has a special duty to 
perform in connection with respiration. 

The Sense of Smell. 

Odorous particles present in the inspired air, passing through the 
lower nasal chambers, diffuse into the upper chambers, and falling on 
the olfactory epithelium produce sensory impulses, which, ascending 
to the brain, give rise to the sensations of smell. It is presumed that 
the sensory impulses are originated by the contact of the odorous 
particles with the rod-shaped olfactory cells of Max Schultze. We are 
still in the dark on this point, though we have every reason to believe 
that any stimulus applied to the olfactory nerves will produce the sen- 
sation of smell, but the proof is not so clear as in the case of the 
optic and auditory nerves. We know that the olfactory membrane is 
the only part of the body in which odors as such can give rise to 
sensations and the sensations to which they give rise are always those 
of smell. Apparently the larger the olfactory surface the more 
intense the sensation ; animals with acute scent have a proportionately 
large area of olfactory membrane. On the other hand, it has been 
disputed that the olfactory nerve is the nerve of smell. Cases have 
been reported of persons who appeared to have a sense of smell and 
yet in whom the olfactory lobes, after death, were absent. 

There is one fact in this connection of which we may be certain, 
that the appreciation by the olfactory nerve of odorous particles 
requires a healthy condition of the nerve, a healthy membrane, and a 
patulous cavity. That olfaction is accomplished entirely by the 
olfactory nerve has been amply demonstrated by physiological ex- 
periment, and is further shown in the fact that the nerve and the 
olfactory bulb are very largely developed in those animals in which 
the sense of smell is unusually acute. 



THE PHYSIOLOGY OF THE NOSE. 49 

The* general sensibility of the membrane is derived from the 
branches of the trifacial, already described. The sense of smell is 
intimately associated with the sense of taste, in that the loss of 
olfaction is always attended by more or less complete loss of the sense 
of taste. This is explained by the fact that the special sense of taste 
is supplied to the tongue from the glosso-pharyngeal nerve and per- 
haps the gustatory, and really consists in the appreciation of either 
the acid, bitter, sweet, or saline character of substances applied to it, 
and nothing more. The nicer appreciation of flavors is entirely the 
result of impressions made on the terminal filaments of the olfactory 
nerve. 

The Function of the Nose in Phonation. 

The nasal cavity performs a most essential part in voice 
production — it is the resonance chamber par excellence. It is upon 
the correct use of the soft palate by which this chamber is opened 
or closed from behind, and the condition and patency of the nasal 
passages, that the "timbre" or quality of the singing as well as the 
speaking voice depends. It is in this cavity that the original tone 
produced in the larynx is most powerfully reinforced and its over- 
tones developed. Any thickening of the mucous membrane or stop- 
page of the posterior or anterior nares gives to the voice that peculiar 
and disagreeable quality known as "nasal twang." Moreover, in 
such conditions articulation is fatiguing and the voice soon breaks 
down with any effort requiring prolonged use, the whole difficulty 
disappearing, as a rule, upon the removal of the obstructing conditions 
in the nose. 

The Function of the Nose in Eespikation. 

The respiratory and phonatory functions of the nose are too often 
looked upon as secondary to that of olfaction, a mistaken view, for 
the nasal passages contain an exceedingly important apparatus con- 
nected with the function of respiration, and one on whose normal 
functional activity depends the integrity of the whole of the mucous 
membrane of the respiratory tract below. 

The real importance of the nose in respiration was first recognized 
by Vierordt, who, I think, was the earliest to emphasize the import- 
ant fact that the air is raised in temperature in passing through the 
nasal chambers. 

While this function of the nose in later years occasioned more 

or less comment, it is really only within a comparatively recent 

date that it has received the attention it deserved. Flint in 1876 

alludes to the fact that the air is moistened in the upper respiratory 

4 



50 DISEASES OF THE NASAL PASSAGES. 

tract, and Rosenthal in 1880 claims that air is already warmed and 
saturated when it reaches the alveoli. 

In a paper on this subject in 1885 J I gave certain views entertained 
in regard to the respiratory function of the nasal chambers, which 
were based largely on clinical observation and which were practically 
the following : 

The normal function of the mucous membrane being to secrete 
mucus, and only in amount sufficient to keep the membrane in a 
soft, moist, and pliable condition, any excess of this amount becomes 
a morbid secretion. Robbed of a small portion of its ninety-three 
per cent of water, it becomes thick, inspissated, and unhealthy. 
Every breath of air that passes through the nasal chambers, and 
reaches the passages below, must become surcharged with moisture, 
otherwise it would rapidly injure the mucous membrane of the air 
passages beyond by robbing them of their moisture, and so rendering 
their mucus thick and inspissated. If the humidity of the inspired 
air be compared with that of the expired air, it will be found that, in 
addition to the other changes as regards carbonic acid and oxygen, 
the inspired air will have gained five thousand grains of water. I 
think I am safe in saying that if five thousand grains of water were 
extracted from the mucous membrane of the bronchial tubes and air 
cells in the course of twenty-four hours, the result would be complete 
destruction of their function, to such an abnormally dry condition 
would they be reduced ; for, as we know, in each act of respiration, 
the inspired air reaches only the larger bronchial tubes, and the source 
of moisture, therefore, of the inspiratory current cannot be from the 
smaller bronchial tubes or air cells. We are, therefore, forced to the 
conclusion that this surplus of five thousand grains is taken up by 
the inspiratory current during its passage through the nasal cham- 
bers, and is still retained by it as it makes its way out through the 
air-passages, for the only source from which this amount of water 
could be taken up is the nasal mucous membrane. The mucous 
membrane of the lower air passages is endowed with no especial 
apparatus for the secretion of water; the only secretory apparatus 
with which it is endowed is in the mucous glands, which secrete 
mucus alone. 

In the nasal mucous membrane, however, we find an apparatus 
capable of furnishing this water, and this is the so-called erectile 
tissue of the turbinated bodies. It is absolutely necessary and essen- 
tial, for the integrity of the lower air passages, that the air which 

1 " Hay Fever, Asthma, and Allied Affections, " N. Y. Med. Jour. , April 24th 
and May 1st, 1886. 



THE PHYSIOLOGY OF THE NOSE. 51 

reaches them should be so far charged with moisture that they should 
not be robbed of any of their secretion. Especially is this true in a 
variable climate like ours, in which so great changes occur, charac- 
terized by excessive humidity or absolute dryness of the atmosphere. 

The great function then of the nasal chambers is to so prepare the 
ingoing current of air that it shall exercise no injurious influence on 
the mucous membrane of the passages below. The nose as a respi- 
ratory organ becomes infinitely more important to us than as an 
olfactory organ. 

The mechanism by which the water is poured out into the nasal 
chambers, and the ingoing current thus surcharged with moisture, is 
in this so-called erectile tissue. The watery constituents of the blood 
transude the mucous membrane, and appear on the tortuous surfaces 
and passages of the cavity. Nature to meet the great demand has 
furnished the membrane in this region with such an abundant supply 
of large tortuous vessels that they assume the appearance of erectile 
tissue, and thus have given rise to this erroneous idea as to their 
function, suggested by the name erectile tissue. The vasomotor 
system of nerves so delicately regulates this function that the trans- 
udation of serum accurately adapts itself to every existing atmospheric 
condition, so that when the air is saturated with moisture no serum 
escapes, when the atmosphere is dry the turbinated vessels are 
charged with blood and the serum is poured out in amount sufficient 
to saturate the ingoing air with moisture, without impairing the 
consistence of the blood in the vessels. This control is so delicately 
exercised as to meet even momentary changes in the humidity of the 
inspired air, and it is readily seen, therefore, how easily any impair- 
ment of this delicate mechanism may occur. 

These views were based on the result of many years of clinical 
observation of this membrane, both in health and disease. 

Since my views were first published, they have been confirmed 
in a very striking manner by Aschenbrandt's exhaustive experiments, 
which show conclusively that the warming of the air in respiration is 
done exclusively by the nose. 

Experiments were also made as to the amount of moisture in the 
expired air. He found that each five litres (five and a quarter quarts) 
of expired air contained 0.18 gramme (2.77 grs.) of water, which con- 
stitutes complete saturation, and furthermore, that the whole amount 
withdrawn from the body in twenty-four hours was 500 grammes 
(7,715 grs.), and that the source of this, therefore, was in the nose. 
A still further conclusion was drawn from these experiments, that all 
mechanical dust is completely arrested during inspiration, and is 
deposited on the moist surfaces of the nasal membrane. 



52 DISEASES OF THE NASAL PASSAGES. 

Subsequent to Aschenbrandt's observations, Kayser made a 
series of investigations in the same line ; eliminating certain sources 
of error in the former's experiments; his results were practically the 
same. 

Kayser also performed a series of experiments for the purpose of 
finding how much the air was warmed in oral breathing, and found 
that the air was heated almost half a degree less than in passing 
through both nostrils. 

As a result of further experiments he found that in its passage 
through the nose or mouth, the air was completely saturated with 
moisture. 

The above experiments, as originally suggested by Aschenbrandt, 
were intended to approximate, as nearly as possible, the conditions 
of normal respiration, the tidal air being taken as iivQ hundred cubic 
centimetres, and the respiration rate as twenty. In thirty seconds, 
then, five litres (five and a quarter quarts) of air would pass through 
the respiratory passages. Kayser points out that at least half the 
time is consumed by expiration and repose, and consequently in the 
experiment the air has been allowed to remain in the nose and mouth 
at least twice as long as it does in normal respiration. He, therefore, 
repeated all of the above experiments, regulating the aspirator so 
that five litres (five and a quarter quarts) would pass in fifteen 
seconds instead of thirty seconds. He found, however, that this 
increased rapidity did not notably influence the result, either with 
reference to temperature or saturation. 

He also found that lowering the temperature of the air before 
aspiration made considerable difference in the temperature of the air 
after aspiration, and that doubling the rate of aspiration also exerted 
an influence upon the temperature and moisture of the air after 
aspiration. 

As a result of further experience as to the filtering out of mechan- 
ical dust in its passage through the nose, Kayser proved that the nose 
is not a perfect filter for mechanical dust. Wurz and Lermoyez hold 
that the nasal mucus not only serves to arrest the irritating particles 
in the atmosphere, but that it plays a much more important role by 
destroying the vitality of a large number of pathogenic bacteria. 

Kayser makes the further observation that when cold air is 
inspired through the nose, there is a notably increased blood supply 
in the turbinated bodies, thereby increasing their heating capacity. 
In this connection he suggests that in tracheotomy the inspired air in 
summer must be of a temperature of 30° (86° F.) to 35° C. (95° R), 
and in winter of 25° (77° F.) to 28° C. (82.4° F.), and in each case 
must be saturated with moisture in order not to produce bronchial 



THE PHYSIOLOGY OF THE NOSE. 53 

irritation; the reason being that the bronchial membrane is not 
endowed with a special apparatus for moistening and heating the air. 

It will be noticed that Kavser makes no definite statement as to 
the amount of moisture poured out by the venous sinuses of the 
nose in the tAventy-four hours. Aschenbrandt, however, makes the 
statement that the whole quantity of water, which the air in respiration 
draws from the human body, amounts to about 500 grammes (7,715 
grs.) in the twenty-four hours, and this is taken from the mucous 
membrane of the nose. This observation was scarcely necessary, 
since the amount given in my original paper, from twelve to sixteen 
ounces, is the amount given by all physiologists as being taken from 
the lungs. Both Aschenbrandt and Kavser, however, make the 
definite statement that all the air which passes to the lungs through 
the nose is in a state of saturation. Of course, saturated air passing 
in and out of the lungs takes absolutely no moisture from the bronchial 
mucous membrane. The general accuracy of these results has re- 
ceived still further confirmation in a series of experiments by Bloch, 
who reaches, practically, the same conclusions as Aschenbrandt and 
Kavser, with the exceptions that he finds that the expired air reaches 
only to two- thirds of the saturation point, and that the heating 
capacity of the oral cavity is inconsiderable. Clinical observation, I 
think, should add sufficient weight to the accuracy of the earlier 
experiments to practically establish the truth of their teaching. 

The proposition is proved beyond question, as previously stated 
by myself, that the sole source of moisture is in the nose. I think 
we may declare it as an established truth, that the function of the 
so-called erectile bodies is serous transudation, and that they are 
designed to subserve no other function in the economy. 



CHAPTER VII. 

GENEEAL CONSIDEEATIONS CONCEENING CATAEEHAL 

DISEASES. 

There are so many misconceptions in regard to what is ordinarily 
called "nasal catarrh," not only among the laity, but also among 
professional men, that it seems wise here to discuss in a general way 
certain questions connected with this subject. Perhaps the most 
prevalent misconception in regard to nasal catarrh is that it is a 
special disease of the nasal cavity, which leads ultimately to ulcera- 
tion of the soft parts with necrosis of bone. This view is the one 
largely encouraged in the advertisements of proprietary remedies for 
the cure of this affection. It scarcely needs to be stated here that a 
simple catarrhal inflammation is always a catarrhal inflammation from 
its onset, and never results in anything more than a simple hyper- 
trophy of the tissues. Ulceration and necrosis belong to syphilis or 
some other of the constitutional dyscrasise alone, and bear no relation 
whatever to the inflammatory process. Another somewhat prevalent 
idea, entertained both by the medical men and the laity, is that there 
is a catarrhal diathesis, a peculiar systemic condition, under the 
influence of which a patient becomes especially liable to catarrhal in- 
flammation, which may attack indifferently any of the mucous mem- 
branes of the body. Patients frequently state that all their mucous 
membranes are weak, and that an inflammation of the mucous 
membrane, say of the air tract, is liable to be followed by a similar 
weakness of the intestinal tract, or possibly of the genito-urinary 
tract. I know of no good ground for this assertion. Certainly my 
own clinical experience fails to justify this view in any manner. 
The mucous membranes of different portions of the air tract are in 
exceedingly close sympathy, and a morbid process in one portion is 
very liable to be followed by a morbid process in another, but that 
there is any sympathy or connection between the mucous membrane 
of the air tract and the mucous membrane of the food tract I do not 
believe. 

There are many who honestly entertain, and many who, for 
commercial purposes, dishonestly encourage the idea that a simple 



GENERAL CONSIDERATIONS. 55 

catarrhal inflammation of the upper air tract has a tendency to lead 
to the development of pulmonary diseases. Possibly a patient with 
a family history of phthisis is more liable to fall a victim to this 
disease with a bad chronic catarrhal affection of the upper air 
passages, than if his upper air passages were in a state of perfect 
health, and yet even this assertion it would be difficult to establish 
on any grounds of clear, clinical observation. The tendency of a 
catarrhal inflammation is to extend downward, but it remains a 
catarrhal inflammation always. The worst outlook, therefore, is in 
the development of a chronic bronchitis with asthma, excluding cases 
of purely nervous asthma, which, while undoubtedly dependent on a 
rhinitis or naso-pharyngeal catarrh, are not directly the result of it, 
but occur only in connection with the peculiar neurotic habit. This 
question, however, is more fully discussed in the chapter devoted to 
the subject of asthma. 

With reference to the use of the term catarrh as describing a spe- 
cial disease of the nasal tract alone, I have rejected it entirely, and in 
place of it have adopted that nomenclature which designates the char- 
acter of the inflammation and the region involved, and simply regard 
catarrh as a symptom of any of the many diseases which may affect 
the upper air tract. 

A very prevalent idea in regard to catarrhal inflammation is that 
its prominent symptom is excessive secretion, either of normal 
mucus or of muco-pus. This is rather a nice question to determine 
in hypertrophic rhinitis. It is altogether probable that this appar- 
ent excessive secretion is really a diminished secretion. In health 
the nose secretes probably a pint of serum, which, becoming 
mingled with the normal mucous secretion, disappears, without 
the patient being conscious of it, by evaporation, the water being 
taken up largely by the inspired current of air. In diseased condi- 
tions the amount of serous exudation is not infrequently diminished 
as the result of hypertrophy, and therefore the mucous secretion, not 
being diluted with this large amount of serum, becomes thick and 
inspissated. A pint of healthy sero-mucus, secreted by a healthy 
membrane, does not make itself felt. Diminish the serous exuda- 
tion one-half, and we have seven or eight ounces of secretion, from 
which the limited amount of water is taken up rapidly ; hence we find 
an inspissated mucous which makes itself felt and gives rise to 
unpleasant symptoms. In atrophic rhinitis the exosmosis of serum 
is more or less completely abolished. The whole secretion of the 
mucous membrane is confined to a mucus largely surcharged with 
epithelial cells, giving rise to a muco-purulent discharge, which is 
dried up by the ingoing current of air, resulting in the formation of 



56 DISEASES OF THE NASAL PASSAGES. 

masses of dried mucus or crusts. We have here a very marked dim- 
inution of secretion, and yet apparently an excess, in that every 
portion of the limited secretion manifests itself in the form of green 
crusts, which give rise to unpleasant symptoms. In a naso- 
pharyngeal catarrh we have an apparent excess of secretion. The vault 
of the pharynx contains in health glands whose function is to pour 
out mucus for lubricating the bolus of food and thus facilitate its 
passage to the stomach. The normal secretion from this region in 
health is large, but it is a thin fluid, and passes into the pharynx in 
even large quantities without the individual being conscious of it. In 
a diseased condition of the naso-pharynx, the secretion becomes 
impaired, and undoubtedly notably diminished, certainly in its 
watery constituents. It is changed into a muco-pus, which, while 
apparently secreted in large quantities, remains a thick tenacious 
mass of mucus adhering to the mucous membrane lining tl^e pharyn- 
geal vault in such a manner that the patient expels it with the 
greatest difficulty ; and hence its presence becomes a source of exceed- 
ing great annoyance. The same I think we may say of the larynx 
and trachea in simple chronic laryngitis and tracheitis, which I re- 
gard as affections almost invariably secondary to diseases of the nasal 
passages. The tract above failing to do its proper duty of warming 
and moistening the inspired air, the parts below are subjected to the 
influence of an abnormally dry current of air in respiration, under 
the action of which the normal mucus is robbed of a certain pro- 
portion of its watery constituents, and, becoming thick and inspis- 
sated, proves a source of irritation, and is expelled with a certain 
amount of difficulty. These diseases are not characterized by an 
excess but by a diminution of secretion, and it is an entire mistake to 
regard excessive secretion as the prominent feature of a chronic 
catarrhal inflammation. A proper appreciation of these diseases will 
be better obtained, I think, when we clearly understand in just what 
manner a chronic inflammation interferes with the very important 
functions which these parts are designed to subserve. This question 
is more fully discussed in a later chapter. I have tried to make 
clear that a nasal catarrh, so-called, means nothing more than that 
there is some diseased condition of the nasal passages. In treating 
such a case our first duty is to make a careful examination of those 
passages to determine what special morbid condition exists there to 
give rise to such symptoms as present. A discharge from the nose 
anteriorly is somewhat uncommon. We should understand that in 
what is called an ordinary catarrh, viz., a liability to cold with more 
or less obstruction to nasal respiration, together with a tendency to 
accumulation of thick mucus in the fauces, we have to do, usually, 



GENERAL CONSIDERATIONS. 57 

with either hypertrophic rhinitis or a naso-pharyngeal catarrh, and 
these are not infrequently complicated with a deformity of the nasal 
septum. We have here the three prominent conditions which give 
rise to an ordinary mucous catarrh, so-called. They are somewhat 
intimately associated in most cases, and it is by no means easy to 
determine just where the morbid lesion lies. Certainly the nasal 
cavity and naso-pharynx react upon each other in a very intimate 
manner. I am disposed to think that in most cases a naso-pharyn- 
geal catarrh is dependent primarily on hypertrophic rhinitis, and that 
an attempt to deal with it is unsuccessful until the hypertrophic 
rhinitis is brought under control. Furthermore, the hypertrophic 
rhinitis in the large majority of instances is dependent upon a de- 
formity of the septum. We have here, therefore, two lesions to 
remove before we can successfully attack the naso-pharynx. More- 
over, it is by no means easy to recognize by the closest rhinoscopic 
inspection what constitutes the morbid lesion in a naso-pharyngeal 
catarrh. Hence we are compelled to remove the disease of the nasal 
passages first, in order to determine that the naso-pharyngeal disorder 
is not entirely dependent upon the nasal. These questions are 
mainly suggested here as illustrating some difficulties in diagnosis, 
and of course will be discussed at length in the chapters devoted to 
their consideration. It may be noted that the idea that a hypertro- 
phic rhinitis gives rise to discharge from the nostril is entirely a mis- 
taken one. It is altogether probable that the perverted mucus which 
accompanies the disease makes its way largely into the pharynx, and 
we thus find that a faucial catarrh, often spoken of as a pharyngitis, 
follicular disease of the pharynx, sore throat, etc., is really a disease 
of the nasal cavities, and in most instances of the mucous membrane 
covering the turbinated bones. 

The character of the discharge, whether anteriorly through the 
nostrils, or through the posterior nares and the fauces, is always 
something of an indication of the form of disease with which we 
have to deal. A purely watery discharge usually indicates a vaso- 
motor disturbance, such as hay fever or nasal rhinorrhcea. A 
profuse sero-mucous discharge in which the serum is more or less 
charged with flakes of grayish mucus, is characteristic of nasal polypi. 
It also occurs in the second stage of acute rhinitis. A thick mucous 
discharge containing flocculi of whitish mucus, and rendered opaque 
by a moderate mixture of young cells, may occur in connection with 
hypertrophic rhinitis, but is usually indicative of a disease of the naso- 
pharynx. This occurs more especially in young children suffering 
from adenoid vegetations of the pharyngeal vault. A thick whitish 
mucus discharged into the fauces, which is drawn down by a nasal 



58 DISEASES OF THE NASAL PASSAGES. 

screatus and expelled by hawking, is characteristic of either 
hypertrophic rhinitis or naso-pharyngeal catarrh. A purulent 
discharge composed of masses of somewhat thick yellow pus, attended 
with something of an odor, should always call attention to the prob- 
ability of the existence of suppurative disease of one of the accessory 
sinuses, usually the antrum in an adult. A similar form of discharge 
occurs in the purulent rhinitis of childhood and in the last stages of 
acute rhinitis. A purulent discharge through the nostrils, mixed 
with shreds of necrotic tissue and blood, and also with offensive 
crusts, indicates the existence of ulceration and probable necrosis, 
and should always suggest syphilis, although small crusts detached 
from just within the margin of the nostril may be discharged from 
slight erosions of the septum. The discharge of greenish crusts, in 
connection with fairly healthy-looking pus, or muco-pus, in connec- 
tion with a mild offensive odor, the crusts being bright yellow or 
greenish in color, and containing neither blood nor necrotic tissue, 
should suggest the existence of atrophic rhinitis. 



CHAPTER VIII. 

ACUTE RHINITIS. 

Acute rhinitis is an acute inflammation of the raucous membrane 
lining the nasal cavities proper, which may confine itself entirely to 
these passages or extend to the pharynx, larynx, and the air passages 
below, and to a lesser degree to the accessory cavities and the Eus- 
tachian tube. These parts, however, are not usually involved in the 
earlier attacks of acute rhinitis. 

Etiology. — It is ordinarily stated that an acute rhinitis is the 
result of exposure to cold and this is undoubtedly true, but behind 
this is a very prominent predisposing cause in an already existing 
chronic inflammation of the nasal mucous membrane, which ren- 
ders the patient especially liable to the occurrence of an exacerba- 
tion on slight exposure. It is often stated that cold in the head 
may arise from the inhalation of acrid vapors, and also that it 
occurs as the result of a peculiar idosyncrasy which renders the nasal 
mucous membrane i:>articularly susceptible to certain odors, such 
as ipecac and iodine. I am disposed to question whether such at- 
tacks are true rhinitis; I am rather disposed to think them a 
temporary disturbance of the great respiratory function of the nose, 
giving rise to what has been called an influenza, or what in its aggra- 
vated form constitutes hay fever or rose-cold ; these affections give 
rise to a morbid condition of the nasal mucous membrane which 
differs essentially from an acute rhinitis. Under the same category 
I should be inclined to place those rare epidemics which are recorded 
in history as having affected large portions of the population where 
they prevailed, such as that described by Anglade, in which an entire 
army was suddenly prostrated with the disease ; or the great epidemic 
of 1762, in which the type of the disease was so severe as to cause a 
mortality of two per cent. It should also be borne in mind that the 
internal administration of iodides is liable to produce nasal symptoms 
closely resembling those of acute rhinitis, which, however are not 
attended with any observable constitutional symptoms. Moreover, 
its action is limited to the production of turgescence of the blood- 



60 DISEASES OF THE NASAL PASSAGES. 

vessels with watery discharges. Iodism runs much the same course 
as an ordinary attack of acute idiopathic rhinitis. 

Symptomatology. — The attack is usually preceded by chilly sen- 
sations, by lassitude and general malaise, followed by a mild febrile 
condition, pains in the muscles, and loss of appetite. These symp- 
toms are not, as a rule, so well marked as the sense of stuffiness about 
the frontal region, with burning or prickling sensation in the nose. 
This lasts some hours and is followed by an acrid, and later by a 
mucous discharge, which soon becomes purulent in character. The 
dryness of the membrane, which characterizes the onset of the attack, 
is coincident with the stage of congestion and arrest of secretion which 
mark the commencement of any acute inflammation of a mucous mem- 
brane. The nasal cavity proper is up to this stage the seat of most of 
the symptoms, which are a sense of discomfort referable to the nose, 
increased secretion, a sense of fulness or closure of the passages, and 
frequent and often distressing attacks of sneezing. If the frontal 
sinuses are involved, the attack is attended with frontal headache. 
Necessarily this is not due to an extension of the inflammatory 
process, but to the congestion of the mucous membrane lining the 
cavity, with pressure upon the nerves. In many cases there is 
marked irritation of the conjunctiva. 

The orifice of the antrum of Highmore is often closed, a somewhat 
grave condition, to be discussed in a subsequent chapter. 

Obstruction of the Eustachian tube, with deafness and ringing 
in the ears, is not an unusual symptom, but is due to obstruction 
and not to extension of the inflammatory action, although it may 
extend to the middle ear. 

The extension of the inflammatory process to the accessory cavities 
seldom occurs ; the pharyngeal vault, however, is often involved, the 
membrane being in a state of mild acute inflammation, the mucous 
membrane swollen, and the pharyngeal tonsil stimulated to an exces- 
sive activity. This is further aggravated by the fact that their 
normal function is interfered with, for, during an attack of acute rhi- 
nitis, the normal mucous secretion becomes thick, viscid, and inspis- 
sated, accumulates in the pharyngeal vault and hinders the normal 
function of the palate ; it prevents the renewal of air in the middle 
ear, obstructs the orifice of the Eustachian tube, and gives rise to 
marked faucial irritation. 

The sense of taste and smell is usually lost for a time. The 
integument about the orifices of the nostrils becomes inflamed from 
the discharge, aggravated by the frequent use of the handkerchief. 

Diagnosis.— An inspection in the first stage shows the mucous 
membrane of the turbinated bones red and swollen, while the surface 



ACUTE RHINITIS. 61 

of the membrane presents a dry and somewhat glazed appearance. 
The nasal cavity is, of course, largely encroached upon by the 
swollen membrane, and a deep inspection, therefore, is not easily 
obtained. In the second stage, the membrane shows a brighter, more 
rose-colored tint, while its surface is bathed in a profuse discharge 
of clear, white, watery serum ; the membrane seems less swollen and 
less highly distended. 

In the third stage a still further change is noted. The secretion 
assumes a bright yellow color, is less in amount, and of a thick viscid 
character. The membrane beneath still presents the appearances of 
active acute inflammation, and the lumen of the cavity is greatly 
encroached upon. 

Posterior rhinoscopy shows each posterior naris more or less 
completely blocked by the swollen membrane of the lower and middle 
turbinated bones, their gross appearance on inspection correspond- 
ing to that of the membrane seen in front, in the different stages of 
the disease. The vault of the pharynx contains a mass of thick, 
yellow, inspissated mucus, adhering to the crypts of the pharyngeal 
tonsil, while the membrane surrounding the Eustachian orifice is 
reddened, but rarely swollen. The lower pharynx oftentimes presents 
a dry, glazed appearance, due to mouth breathing from obstruction 
of the nasal passages. It may be somewhat reddened but is not, as a 
rule, in a state of active inflammation, not being a part of the air 
passages. Acute as well as chronic inflammation of the regions 
confines itself to the physiologically associated tracts, and in extend- 
ing down it passes immediately from the nasal passages to the 
larynx and trachea. 

When the latter are involved, they present the same appearances as 
are found in ordinary subacute catarrhal inflammation of these regions. 

Prognosis.— The prognosis in this disease is favorable. It in- 
volves no danger to life and will run its course, as a rule, in about 
seven days without interference, leaving behind it probably, however, 
an aggravation of the chronic condition which undoubtedly underlies 
and is the most prominent predisposing cause of the acute inflam- 
mation. 

It is understood, of course, that this statement applies to those 
cases in which the accessory sinuses are not involved, and in which 
there are no aural complications. 

Prophylaxis. — Those who are especially liable to take cold should 
exercise additional carefulness in the avoidance of those causes which 
experience teaches them may give rise to an attack of acute rhinitis. 
Yet an excessive zeal in this direction is always to be avoided, for 
muffling the head and neck with too much covering invariably leads 



62 DISEASES OF THE NASAL PASSAGES. 

to an oversensitiveness of the parts. It must be borne in mind that 
exposure to low temperature alone is not sufficient to produce a cold. 
It is a draught of damp air, usually of a mild temperature, which causes 
the mischief. We do not protect the throat by wrapping the neck ; we 
weaken it. There are few measures of greater value as a preventive 
of colds than the daily use of a cold plunge bath. This not only acts 
to keep the emunctory functions of the skin in a healthy state of 
activity, but also serves to harden the parts and render them less 
susceptible to the action of cold. It is, however, a measure that 
we cannot recommend in all cases, and if the cold plunge is not 
feasible, sponging the body with cold water to the waist every morn- 
ing is a measure of undoubted benefit. Of more importance still as 
a preventive measure is the removal of that condition which predis- 
poses to acute rhinitis, namely a chronic rhinitis. Perhaps no fact 
has been more noticeable in my practice than the rarity with which 
patients take cold after 'commencing treatment for a chronic rhinitis, 
even the slight improvement secured by one or two applications being 
sufficient to control this tendency. Too much stress cannot be 
laid on the fact that in all cases the habit of taking cold means a 
chronic rhinitis, although this may be of so mild a character as to 
give rise to no marked symptoms, other than this special suscepti- 
bility to cold. 

Teeatment. — An attack of acute rhinitis may often be aborted if 
measures are resorted to sufficiently early. This must needs be done 
very soon after the first local symptoms appear, and, as a rule, before 
the discharge of watery serum which marks the second stage of the 
attack. From five to ten grains of quinine, followed by some warm 
drink, such as chamomile tea, or a hot lemonade, with the addition 
perhaps of a hot footbath will often arrest the attack. If there is 
frontal pain or facial neuralgia, ten grains of Dover's powder may 
be given with advantage. A popular measure to break up a cold is 
the Turkish bath. A Turkish bath is a luxury in health, but I question 
its efficacy as a remedial agent in acute rhinitis, not to mention the 
danger of exposure on leaving the bathing establishment after the 
profuse perspiration. This danger is obviated and the good effect 
of a hot bath secured by following the excellent suggestion of Cohen, 
who recommends that the patient be given a hot-air bath immediately 
before retiring, by wrapping himself in a warm flannel sheet and 
sitting in a chair under which an alcohol lamp is placed. The bath 
should last from fifteen to twenty minutes. A profuse perspiration 
is usually the result, and the patient should then wrap himself in the 
same blanket and retire to his couch. Some warm drink should be 
taken immediately after the bath. 



ACUTE RHINITIS. 63 

The early administration of opinm presents a remedy of undoubted 
efficacy in mitigating the severity of the attack and oftentimes in 
completely aborting it. This measure, which belonged to the practice 
of the olden times, receives the indorsement of Mackenzie, who gives 
preference to the use of the tincture of opium, advising its administra- 
tion in doses of from five to seven drops on an empty stomach, to be 
repeated, if necessary, at the end of from six to eight hours. Lees 
expresses preference for bromide of potassium with belladonna, ad- 
ministered to the extent of producing dryness of the fauces. Bever- 
ley Robinson advises the use of a powder of belladonna (grs. xx.) and 
morphine (grs. ij.), to be thrown into the nose at intervals of three or 
four hours by an insufflator. Both Sajous and Bobinson advise small 
quantities of tincture of aconite, in combination with some form of 
opium, when the fever is unusually high. 

A very common procedure among physicians is to confine their 
patients with a cold in the head to their rooms or even to their bed. 
I am by no means sure that this is wise in all cases. Confinement 
to the house should be enjoined during inclement weather, but even 
in the height of an acute rhinitis I have frequently seen benefit from 
a brisk walk in the open air in the middle of the day, when the sky is 
clear and the air not too cold. Confinement to bed is unnecessary, 
unless the constitutional symptoms are aggravated, or serious compli- 
cations threaten involvement of the accessor}' sinuses or an attack 
of middle-ear disease. 

The foregoing suggestions are made as specially indicated in the 
first stage of the disease, and before the discharges have set in, with 
the idea of arresting the further progress of the attack. In the later 
stages of the disease we have to deal with the vexatious element of 
excessive secretion, together with the nasal stenosis. 

In the latter stage astringents may be exhibited, such as tannin 
and zinc, but in my opinion they are of very little use in diminishing 
the excessive discharge which characterizes the later stages of the 
disease. If nitrate of silver be used, its better administration would 
be in the proportion of two grains to the ounce incorporated with talc. 
Michael, of Hamburg, advises the use of this drug in the strength of 
one part in twenty. Inhalations of benzoin, lupulin, oil of tar, 
creosote, oil of pine, turpentine, camphor, etc., may also be used. 
A homely but convenient method of inhalation is to place from one 
to four teaspoonfuls of any of the above drugs in an open-mouthed 
bottle, or even in an ordinary coffee cup, and pour over it half a pint 
of water of about the temperature of 160° F. This being held near the 
face, the vapor of it is drawn in through the nose, or, if that is impos- 
sible, drawn through the mouth and expelled through the nose. The 



64 DISEASES OF THE NASAL PASSAGES. 

fumes of chloride of ammonium have, for a long time, enjoyed a well- 
deserved popularity, not only in the cases under consideration, but 
in all catarrhal affections of the respiratory tract. Their action, as 
I conceive it, is not to diminish secretion or limit the catarrhal 
process, but to stimulate the membrane to a certain extent ; to dilute, 
as it were, the mucous discharge, and render its expulsion easier. 

While these remedies possess unquestioned value in the treatment 
of this disease, in cocaine we have a remedy whose action is definite 
and absolutely certain in controlling what is probably the most dis- 
tressing feature of the attack, namely, the venous turgescence. The 
peculiar action of cocaine on the blood-vessels has already been 
referred to and need not be entered upon here, but the promptness 
and certainty with which the blood from the mucous membrane is 
expelled upon its application, whether in a normal state or in a state 
of inflammation, are absolute. This action, however, of cocaine, lasts 
but three or four hours, when it is followed by relaxation of the 
blood-vessels, not by a reaction, as has been claimed by many 
writers. The question arises, then, how far may we depend upon 
this drug to permanently control acute inflammation of the nasal 
membrane when it is administered every four hours? My own expe- 
rience teaches me that when the action of cocaine has exhausted itself, 
the blood-vessels do not return to their original highly distended 
condition ; so that, if in an acute rhinitis we repeat the application of 
cocaine as soon as the patient experiences any sensation of recurring 
stenosis, we may eventually curtail the duration of the attack, if we 
do not completely arrest it and keep it under control. In cocaine, 
then, I believe we possses a remedy whose value cannot or should 
not be questioned, and the efficacy of which is far greater than that 
of any other single drug, and probably than those above-mentioned 
combined. 

A favorite method of administration is as follows : 

I£ Cocainse hydroclilor., . . grs. xx. 

Morphinse, . grs. ij. 

Aquae, . . . . , 3 i. 

Ft. solutio et adde, 

Cosmolini liquid 1 i. 

This is to be used in the Burgess atomizer. The above prescrip- 
tion makes an excellent and nearly permanent emulsion, though, be- 
fore using, it is well that the atomizer should be thoroughly shaken. 
An objection to the fluid cosmoline ordinarily sold by druggists is 
that it contains a considerable amount of the volatile oils of petroleum, 
notably the kerosene, which gives a rather unpleasant odor and taste 
to the mixture. A preferable oil, but one not generally in the mar- 



ACUTE RHINITIS. 65 

ket, is the Voschano oil, which, I believe, is the Russian petroleum 
product. 

The immediate effect of this application is exceedingly agree- 
able and pleasant, and, if its use is continued, an ordinary cold in 
the head may be rapidly brought under control. 

If the above mixture and apparatus are not available, an ordinary 
watery solution of cocaine acts as an excellent substitute. It is well, 
however, in applying the watery solution of cocaine, to bear in miud 
that, when the nose is in a highly sensitive state, its reaction is mildly 
acid. This may produce an unpleasant effect; hence a sufficient 
amount of bicarbonate of soda should always be added to render the 
solution alkaline. 

As a matter of convenience, cocaine may be given in the form 
of a powder, although it is doubtful if any snuff reaches the parts 
with the same degree of thoroughness as a fluid. An excellent for- 
mula for this is : 

I£ Cocainae hydrochlorat., grs. x. 

Pulv. magnesia?, 3 ss. 

Camphor is a popular remedy, and is a valuable adjuvant in the 
relief of acute coryza, if well diluted and used in a small quantity. 
Several serious accidents have been reported from its indiscriminate 
use. The above formula may be used with the addition of three 
grains of powdered camphor. 

The various preparations of mint form both an agreeable and effi- 
cacious remedy in catarrhal affections of the nose. 

After the vascular plethora has been brought somewhat under 
control, and the profuse serous exudation has diminished, I find it 
an excellent practice to make an application of chromic acid directly 
to the swollen membrane. This is done, not with the idea of de- 
stroying tissue, but, in the method described fully in the chapter 
on hypertrophic rhinitis, as affording us one of our most effective 
remedies for directly controlling an inflammatory process. The 
membrane having been thoroughly contracted with cocaine, and 
cleansed by repeated wiping with pledgets of cotton, one or two small 
crystals of chromic acid are applied to the face of the mucous 
membrane covering the lower turbinated bone, making a small eschar, 
whose office is to pin down the swollen membrane and prevent a re- 
turn of blood to the part. This may seem a somewhat irrational 
mode of procedure, and yet it is one which, if deftly accomplished, 
will often secure results of a most gratifying character. If this 
measure fails and we find that, after the cauterization, the membrane 
swells to its original contour, we shall have done more harm than good 
by our efforts ; hence exceeding great care should be exercised that 
5 



(56 DISEASES OF THE NASAL PASSAGES. 

the tissues be thoroughly contracted before the acicl is applied, and, 
furthermore, that the caustic should be so laid on as to burn deeply 
into the membrane over a limited area, rather than spread broadly 
over its surface. 

Before closing, mention should be made of the great value of dry 
heat applied externally over the forehead. A nice way of accomplish- 
ing this is by means of the small hot- water bags sold in the drug 
stores, which can be bound upon the forehead and allowed to remain 
in situ for several hours at a time. The relief to the frontal headache 
and to the sense of distention or fulness across the root of the nose is 
often very striking, while at the same time the inflammatory action is 
probably modified to an appreciable degree. 

The remedy suggested by Woakes for the controlling of neuralgic 
pain accompanying the disease may well be resorted to in cases in 
which the usual narcotics either fail of their action or are not well 
tolerated. He recommends that gelsemium be given in the form of 
the tincture, in doses of ten minims each, to be repeated every three 
hours until relief is obtained. A more potent remedy and an exceed- 
ingly agreeable one is aconitine, which may be given in doses of one- 
two-hundredth of a grain every three hours, care being taken to note 
the occurrence of the peculiar prickling of the fauces, with numbness 
of the tongue or extremities, which indicate the limit of toleration of 
the drug. 

If, during the course of the attack, symptoms should appear of 
threatened involvement of one of the accessory sinuses, resort must be 
had to measures of a most active character to prevent so serious an 
accident. These consist mainly in the moderate use of anodynes and 
active counter-irritation, with local blood-letting. If the frontal sinus 
or the antrum of Highmore is in danger, dry cupping immediately over 
the part should be resorted to, and if this fails of relief no hesitation 
should be felt in immediately applying a blister. At the same time 
it will be found that the application of water to the nasal chambers, 
as hot as can conveniently be borne, will aid much in arresting this 
serious complication. This is usually accomplished by the ordinary 
fountain syringe, additional hot water being added to the reservoir as 
the flow is established through the nares. 

Schech advises the use of leeches to the root of the nose in these 
cases. This local blood-letting is accomplished without involving the 
temporary disfigurement which attends the blister or cupping, but I 
question if it is as efficacious. 

If inflammation of the middle ear is threatened, vesicating collo- 
dion may be applied in front of the tragus, but a more effectual 
remedy probably in this case would be in the use of leeches, in addi- 



ACUTE RHINITIS. 67 

tion. Politzeration, as recommended by Woakes, may be resorted 
to, although this measure should be used with the greatest caution. 
Schech further recommends incision of the membrana tympani, 
although Buck questions the advisability of this, when the morbid 
process is of a simple catarrhal nature, on the ground that the in- 
cision speedily closes, and, furthermore, while open it may admit of 
the entrance of disease germs. The warm douche, of course, should 
be freelv used in the external ear. 



CHAPTER IX. 

HYPEKTKOPHIC RHINITIS. 

This is a chronic inflammation of the mucous membrane lining the 
nasal cavities, characterized by a permanent dilatation of the blood- 
vessels, with increased thickening of the intravascular tissues, as a 
result of which the normal lumen of the nasal passages is so far en- 
croached upon as to interfere with free nasal respiration. In addition 
to this, and what is of still more serious import, the respiratory func- 
tion of the pituitary membrane is seriously affected and the mucous 
membrane lining the air passages below is subjected to such abnormal 
conditions as lead ultimately to the development of secondary in- 
flammatory processes in this region. 

Probably in no single disorder of the upper air passages is a thor- 
ough understanding of its causes, development, and symptoms more 
important than in the one under consideration, for, as I firmly be- 
lieve, a morbid process setting in primarily in the nasal mucous mem- 
brane is the cause of a large number of secondary affections involving 
not only the air passages below, but also organs having no especial 
physiological or regional connection with the nose. 

Etiology. — Taking cold figures in medical literature as a probable 
cause of most of the acute inflammatory diseases of the upper air pas- 
sages, and chronic inflammation is said to be the result of repeated 
attacks of acute inflammation. My own belief, however, is that the 
chronic inflammation sets in first, and that repeated attacks of acute 
inflammation become the prominent features of the chronic morbid 
process. 

Climatic conditions also are said to exercise an unfavorable influ- 
ence on the development of catarrhal diseases. But I do not think 
that climate is an important factor in the production or causation of 
nasal catarrh, and I will content myself with the statement that cli- 
matic influences on catarrhal process are temporary only, whether in 
improving or in causing an aggravation of the trouble. I have no 
disposition to underestimate the value of a change of climate, but I 
think we are never justified in giving hope that it is going to afford 
anything but temporary relief in ordinary catarrhal disease of the 



HYPERTROPHIC RHINITIS. 69 

upper air passages. In those cases, however, in which the disease 
has given rise to a severe laryngitis or a bronchitis, a change of resi- 
dence to a more favorable climate often becomes imperative. 

Catarrh is often designated as an American disease, and without 
stopping to question the truth of this assertion search has been made 
for some peculiar quality of our climate which has given rise to the 
universal affliction. I think it is very doubtful if the American peo- 
ple suffer more generally from catarrhal disorders than those living 
in the same latitudes on the other side of the ocean. Certainly the 
general assertion is a somewhat loose one, not based on careful obser- 
vation. I believe the origin of this mistaken view to be largely due 
to the fact that diseases of the nasal cavities engaged the earlier and 
more industrious attention of specialists in this country than in Eu- 
rope, and a survey of our literature would naturally lead to the con- 
clusion that nasal disease was exceedingly common here. 

The assertion is also made, in searching for a cause of American 
catarrh, that it is due to our dry and dust-laden atmosphere. 

My own experience teaches me in this connection that, whereas a 
dust-laden atmosphere may be a source of discomfort and irritation to 
the nasal passages, yet as an efficient factor in the production of or- 
ganic changes in the deep tissues cf the membrane it is greatly over- 
estimated. We have no reason for saying that workers in tobacco 
or carpet factories, or in mines, suffer as a rule from nasal disease ; 
workers in coal mines inhale the dust of coal to such an extent that 
the lung tissue itself is oftentimes stained with the carbon, yet this 
occurs without involving these delicate structures in serious dan- 
ger. When we consider the far greater vulnerability of these tis- 
sues than the tissues affected when the dust enters the nasal cavities, 
the fact referred to would seem to go far toward establishing the view 
that a dust-laden atmosphere is comparatively harmless to the mucous 
lining of the upper air tract. 

As regards the influence of tobacco on catarrhal diseases, I can 
only repeat here what I stated in a former work : " The progress of 
the chronic pharyngitis is marked, of course, by repeated acute at- 
tacks of ordinary sore throat. The use of tobacco is very generally 
supposed to produce and aggravate chronic pharyngitis. Tobacco 
smoke is without question an irritant to the mucous membrane of the 
air passages, especially if inhaled in a concentrated form. On the 
other hand, it is also true that the mucous linings easily become 
inured to the action of the smoke, so that breathing or inhaling an at- 
mosphere charged moderately with it is tolerated with immunity. 
Cubans are, perhaps, among our most inveterate smokers, and yet they 
suffer somewhat rarelv from throat catarrhs. 



70 DISEASES OF THE NASAL PASSAGES. 

" I do not wish to say that the use of tobacco may not exercise an 
injurious influence on the throat, but that this is the result of the 
direct contact of the smoke with the membrane I regard as very im- 
probable. The effect of smoking in producing gastric disturbance, 
as shown in the various forms of dyspepsia with which excessive 
smokers suffer, and this, in turn, leading to the aggravation of an ex- 
isting pharyngeal catarrh, would seem to me to present the true ex- 
planation of the injurious action of the habit on the throat. And so, 
while I condemn the use of tobacco as a vicious habit, and assert that 
its excessive use may exert a very injurious influence upon the throat, 
I wish it to be understood that I consider the pernicious influence an 
indirect one, and not due to the contact of the smoke with the mucous 
lining of the upper air passages." 

The question of diathetic conditions, as influencing catarrhal dis- 
orders, figures largely in our older literature, many writers even as- 
serting that there exists a true catarrhal diathesis. My own observa- 
tion leads me to the conclusion that catarrhal diseases of any mucous 
membrane are largely local in character, and that any constitutional 
disturbance which accompanies them is secondary in character. 
Certainly I have never met with any case which seemed to me to pre- 
sent evidence of a catarrhal diathesis. 

How far the rheumatic or gouty habit may influence catarrhal proc- 
esses is an exceedingly nice question to decide. Rheumatic or gouty 
pharyngitis is undoubtedly met with, but the pharynx, as I believe, 
has no physiological connection with the breathing apparatus. Catar- 
rhal inflammation of the nose due to the gouty or rheumatic dia- 
thesis I have not met with. 

The graver dyscrasise, such as have been called the tuberculous and 
scrofulous diatheses, undoubtedly exert a predisposing influence to 
catarrhal diseases, if we use this term in the sense of an unhealthy or 
excessive discharge from the nasal passages. It is doubtful, however, 
if they ever lead to the production of connective-tissue hyperplasia, 
the prominent condition which obtains in the disease under consider- 
ation. Their influence is, then, to aggravate the symptoms of an 
existing catarrhal inflammation, and perhaps hasten the hypertrophic 
process, rather than a clearly causative influence in the development 
of the inflammatory action. 

By far the most frequent cause of hypertrophic rhinitis, I believe, 
is deformity of the nasal septum, giving rise to nasal stenosis, and 
occurring usually in the anterior portion of the passage. Its method 
of development is, to a certain extent, mechanical, and may be ex- 
plained as follows : During infancy or childhood, as we know, the 
cartilages and bones of the nose are soft, and especially subject to 



HYPERTROPHIC RHINITIS. 71 

injury. The child has a fall and strikes, naturally, the most promi- 
nent feature of the face ; or again, in childhood or youth a blow on 
the nose is one of the most frequent accidents. In many cases the 
accident gives rise to noticeable symptoms; in a far larger num- 
ber of cases, however, the injury causes mere temporary discomfort, 
the symptoms pass away, and the accident probably is forgotten. 
Now, in the case of fracture with resulting deflection of the septum, 
the symptoms may develop with considerable rapidity, whereas, in 
other cases, a mild deformity takes place, and a low grade of inflam- 
mation sets in, which becomes extensive as time lapses. In every case, 
however, the effect is a stenosis of the nasal cavity. The immediate 
result of stenosis is a gradually developing permanent hyperemia or 
distention of the blood-vessels, which not only causes hypertrophic 
changes, but is followed by a certain amount of shrinking, as it were, 
in the tissues ; not the atrophy which we meet with in atrophic rhi- 
nitis, but a bloodless condition of the vessels due to abolition of func- 
tion. The result of hyperemia, of course, is to increase nutrition, 
and we have, as a consequence, true hypertrophy taking place, a per- 
manent structural thickening of the membrane. 

The point which I endeavor to make, that traumatism is the origi- 
nal cause of so large a proportion of these cases of hypertrophic rhi- 
nitis, is, I think, an exceedingly important one, and I repeat again 
that an essential point of this theory is the fact that the injury itself 
antedates the morbid symptoms, oftentimes many years, and that the 
development is essentially an exceedingly slow process. 

Deformities and deflections of the septum are by no means the 
only cause of nasal stenosis. Any deformity which causes narrowing 
of the nostril, will produce the same train of symptoms. A displace- 
ment of the triangular cartilage of the septum I have seen act in the 
same manner. Weakness of the dilator muscles of the nostril also, 
although rarely, is a very efficient factor in the production of hyper- 
trophic rhinitis. Deformity of the alar cartilages, by which the 
normal aperture of the nostril is narrowed, we occasionally meet with 
acting in the same way. Not infrequently we find cases in which 
hypertrophy has taken place without any mechanical stenosis ; these 
may be attributed to taking cold, for, while undoubtedly the habit 
of taking cold is due primarily in these cases to the chronic inflam- 
mation, which in the majority of instances is caused by deflected 
septum, we must acknowledge that repeated attacks of acute inflam- 
mation may precede the chronic process. 

Symptomatology. — The prominent symptoms resulting from this 
condition are due primarily to changes in the normal secretion of 
mucus. As we have already learned in the chapter on the physiology 



72 DISEASES OF THE NASAL PASSAGES. 

of the nose, the secretion in health consists of a limited amount of 
mucus together with a very large amount, a pint or more, of serum, 
whose source is in the venous sinuses in the deep layer of the mem- 
brane. Now, the deposit of connective tissue in the intervascular 
tissues, giving rise to notable thickening, necessarily results in an 
obstruction to this exosmotic process. The amount of serum which 
transudes is diminished, while at the same time the blood-vessels, 
not being unloaded by normal transudation, become distended. The 
discharge from the nose itself, instead of being a sero-fluid mucus, 
becomes thick and inspissated. The sero-mucus, which in health 
makes its way into the fauces and disappears, now shows a tendency to 
lodge in the nasal chambers, or, flowing back into the posterior part 
of the lower meatus, is hawked back by a sort of nasal screatus into 
the pharynx. 

There is no tendency whatever to the formation of crusts, or in- 
spissated masses, nor do foetid and offensive secretions accompany 
this form of catarrhal disease. If such symptoms are present, they 
should always be regarded as evidence that some other form of dis- 
ease is to be dealt with. 

The popular fear in regard to nasal catarrh is that sooner or later 
it will result in offensive discharges. This is based partly on the 
teaching of irregular practitioners that catarrh, so-called, leads to 
ulceration and necrosis. Ulceration and necrosis belong in no possi- 
ble manner to hypertrophic rhinitis, but are met only in connection 
with syphilis, scrofula, and other grave diseases. This theory of 
offensive discharges occurring in this disease is based also on the 
teaching that atrophic rhinitis is a later stage of hypertrophic. It 
is, I believe, based on absolutely incorrect clinical observation, as 
the two diseases are, from the commencement, totally separate and 
distinct in character, as will be shown when we come to the discussion 
of atrophic rhinitis. The foetid odor met with in connection with 
hypertrophic rhinitis, I have been able in every case to trace to the 
mouth. The patient sleeping with the mouth open, -the tongue be- 
came dry and furred, and the thick velvety epithelium on its dorsum 
was the source of slightly offensive odor, which persisted for some 
hours, perhaps, after arising in the morning. Or it may be traced 
to the existence of decayed teeth, amalgam fillings in the teeth, etc. 

Nasal stenosis with mouth breathing is always a prominent symp- 
tom of the disease. Mouth breathing is often considered to be a 
habit, but is probably a necessity due to the fact that the individual 
cannot get air enough through the nose, and hence is compelled to 
open the mouth. 

In consequence of the impairment of the normal function of the 



HYPERTROPHIC RHINITIS. 73 

nose, under which the exudation of serum is interfered with, we soon 
have certain changes setting in in the air passages beyond. The first 
to become affected is the vault of the pharynx; the normal secretion 
of mucus in the ■ pharyngeal vault becomes thick and inspissated, 
and adheres to the parts in a thick tenacious plug, which hangs down 
behind the velum of the palate, causing excessive annoyance and 
oftentimes distress to the patient. During waking hours this is not 
so noticeable, on account of the voluntary efforts of the patient in 
clearing the nose and fauces. During sleep, however, this pharyn- 
geal mucus accumulates in a large mass, the removal of which in the 
morning occasions a considerable effort to the sufferer. 

Fuithermore, the pharynx becomes excessively irritable, and the 
hawking and coughing in the morning is often attended with retching 
and vomiting. 

This faucial accumulation is usually spoken of as nasopharyngeal, 
or post-nasal catarrh. In very many cases, however, we can undoubt- 
edly trace its development to a previously existing disease of the 
nasal passages proper, in the manner above outlined. That it is 
met with, however, as an independent disease cannot be questioned, 
but even in such a case there is still an intimate pathological connec- 
tion between the two regions, under which they naturally react, the 
one upon the other. 

Catarrhal inflammation of the lower pharynx does not occur in 
connection with rhinitis, but we not infrequently find the scattered 
follicles along the surface of the pharynx enlarged and inflamed, 
together with the chain of glands immediately behind each pillar of 
the fauces. This follicular enlargement is probably entirely the re- 
sult of the nasal disorder. It gives rise, however, to no marked 
syniT>toms, as a rule, except in nervous, hysterical female patients. 
As the disease progresses, we find the larynx, trachea, and air pas- 
sages beyond involved in a mild catarrhal process. This is not due 
to any extension of disease from the nasal passages, but is due to the 
same cause which gave rise to the pharyngeal symptoms, and follows 
very soon upon their appearance. The air, reaching the larynx and 
trachea in an abnormally dry condition, robs the mucous secretion in 
these organs of its moisture and renders it thick and inspissated. 
Its fluidity being destroyed, it adheres closely to the membrane and 
gives rise to irritation and subsequently to a mild inflammation. As 
this secondary laryngitis and tracheitis sets in, we find a rather curi- 
ous development of the disease occurring. Heretofore the patient, 
as the result of exposure, suffered from cold in the head. Now his 
colds result in a laryngitis or bronchitis, which, running a somewhat 
slow and persistent course, seems to travel upward. A cold in the 



74 DISEASES OF THE NASAL PASSAGES. 

head sets in oftentimes days after a bronchitis or a winter cold. 
This is not the rule, but is of very frequent occurrence. Why it 
should be so, I do not pretend to explain. Certainly it is not due to 
the fact of any improvement in the nasal condition, for that is pro- 
gressive so long as it is allowed to go on without treatment. 

Elongated uvula not infrequently occurs in connection with 
chronic rhinitis, and probably is a direct result of the faucial irrita- 
tion set up in the later stages of the disease. 

Cough also is not infrequently present, and oftentimes constitutes 
an exceedingly troublesome symptom. This may be present during 
acute exacerbations only, or it may complicate the chronic affection. 
It is often referred to as a reflex cough due to intranasal disease. 
I do not think it necessary to bring in this obscure explanation of the 
symptom, when it is so evidently a direct result of the catarrhal 
process. In most cases, probably, it is due to the nasal stenosis, 
causing habitual mouth breathing with a resultant dryness of the 
larynx and trachea. In other cases it is due to the catarrhal inflam- 
mation which sooner or later involves the whole upper air tract, in 
the one case giving rise to a dry, hacking, irritating cough, unaccom- 
panied by secretion, while in the other case there is a moist cough 
with more or less profuse expectoration. 

Symptoms referable to the ears I believe to be present in a far 
larger proportion of cases than is usually recognized by our standard 
authorities either on throat or on ear diseases. Deafness is perhaps 
the earliest and most easily recognized symptom with which we meet 
in this connection, and yet this is a somewhat vague expression. A 
moderate diminution in the hearing distance as tested by the watch 
will probably be recognized in a very large proportion of cases of 
intranasal disease, and yet when this diminution is but moderate it 
is not always safe to say that it constitutes a morbid condition 
directly due to the nasal disease, especially when we remember that, 
while the watch test is perhaps the best we possess for testing the 
hearing, yet it is an exceedingly unreliable and uncertain ooe. We 
should avoid, therefore, attaching too great importance to it. 

Disease of the middle ear, as recognized by notable impairment of 
hearing, retraction, atrophy or calcification of the membrana tym- 
pani, together with obstruction of the Eustachian tube as determined 
by politzeration or the use of the catheter, is by far the most frequent 
morbid condition of the auditory apparatus met with in connection 
with intranasal disease. This affection is undoubtedly a direct re- 
sult of the hypertrophic process in the nasal chambers. 

In a certain proportion of cases of hypertrophic rhinitis, tinnitus 
aurium is met with, usually in connection with middle-ear disease, 



HYPERTROPHIC REINITIS. 



75 



though in a smaller number of cases there is apparently no organic 
lesion. That this distressing symptom may be dependent on the 
nasal disease is shown by the fact that, in a flattering proportion of 
cases, it disappears under treatment, and even in those instances in 
which complete cure is not accomplished marked relief is afforded. 

Hypertrophic rhinitis is also a prominent factor in the causation 
of attacks of hay fever and asthma. This, however, will be dis- 
cussed in the chapters devoted to those affections. 

Headaches, eye troubles of various kinds, together with a large 
number of nervous diseases, such, as chorea, epilepsy, etc., occur 
also in connection with intranasal disease. The discussion of this 
relation is more properly relegated to the chapter on nasal reflexes. 




Fig. 26.— Hypertrophic Rhinitis. X 500. a, Epithelial layer ; />, limiting structureless membrane ; 
c, adenoid layer ; d, blood-vessels filled with blood ; e, acinous gland ; /, venous sinus consti- 
tuting a part of the so-called erectile tissue. 



Pathology. —The accompanying cut (Fig. 26) represents a section 
of a mass removed from the posterior portion of the lower turbinated 
bone. The changes may be described as follows : The whole mucous 
membrane is markedly thickened and deeply corrugated. The epi- 
thelial layer is -augmented or increased in width. The outermost 
layer of epithelium in specimens from the middle turbinated bones 
exhibits fine ciliae, while in sections from the lower turbinated bones 
the ciliae are occasionally wanting in places. There are deep valleys 
running downward into the adenoid layer which are filled with strati- 
fied epithelia. The latter consist of elongated epithelia, ten to twelve 
layers in diameter. The layer nearest the adenoid tissue is occupied 



76 DISEASES OF THE NASAL PASSAGES. 

by distinctly developed large columnar epithelia, which, especially 
where they go to fill the valleys, are very large and composed of 
several strata. The boundary line between the epithelia and the 
adenoid tissue is everywhere well marked, and in some places there 
is even present a layer without distinct structure, the so-called struc- 
tureless membrane. 

The characteristic features of hypertrophy of the nasal mucous 
membrane, then, may be briefly summarized as follows : 

First. — Increase of the covering epithelium, without desquama- 
tion. 

Second. — Increase of the adenoid layer and its capillaries, with 
stagnation of blood, together with a new formation of fibrous connec- 
tive tissue replacing the adenoid layer. 

Third. — Increase of the racemose glands, both in the adenoid and 
submucous layer. 

Fourth. — Hypertrophy of the connective tissue between the en- 
larged veins in the submucous layer. 

Fifth. — In advanced stages of the hypertrophic process, an ab- 
sence of lymph corpuscles, they having evidently been transformed 
into connective tissue. 

At the anterior termination of the middle turbinated bone, the 
hypertrophic process develops in a somewhat different manner, in 
that, while there is still evidence of inflammatory action, the thick- 
ening of the membrane is largely due to a myxomatous transforma- 
tion, which gives to the tissue a somewhat soft, gelatinous consist- 
ency, with a gross appearance closely resembling that of an ordinary 
nasal polypus. 

Diagnosis. — The question has been raised as to what constitutes 
a diseased condition of the nasal mucous membrane, and whether we 
can recognize it in its milder forms by sufficiently characteristic ap- 
pearances. I think not only that we can do this, but that we should 
do so in all cases, with the same delicacy of appreciation as is used 
in the recognition of diseased conditions of other organs, and this by 
ocular inspection; for since the introduction of the use of cocaine we 
are enabled to bring into view the whole of the nasal cavities, in a 
manner so thorough that no morbid process existing there should 
escape notice. 

An examination anteriorly will show the mucous membrane 
swollen and of a bright reddish-gray color, with perhaps a pink 
tinge. This is not the bright scarlet color of acute inflammation, nor 
again the purplish hue of purely venous congestion, but something 
between the two, the swollen condition being, as we know, due en- 
tirely to the plethoric state of the venous sinuses, although the super- 



HYPERTROPHIC RHINITIS. 77 

ficial color is given by the hyperemia of the capillaries of the mucosa 
proper. The surface of the membrane is rounded, somewhat irregu- 
lar in shape, and coated with a limited amount of grayish semi- 
transparent mucus. If the swelling is but moderate, we may inspect 
a considerable portion of the membrane covering the lower and mid- 
dle turbinated bones. 

On the lower turbinated, behind its anterior extremity, we find 
the surface presenting a slightly rugous appearance, while on the 
middle turbinated we notice a brighter red color, together with a 
smooth, shining surface, but slightly coated with mucus, and, accord- 
ing to the extent of the turgescence, approaching more or less closely 
toward contact with the septum. If there is considerable swelling of 
the membrane, we find also the lower turbinated bone approximating 
itself to the septum, thus rendering an inspection of the cavities be- 
yond impossible. 

Examination posteriorly simply brings into view the membrane 
covering the posterior termination of the middle turbinated bone, 
together with the posterior half or two-thirds of that of the lower 
turbinated bone. We find here an appearance differing essentially 
from that seen in front. The membrane here presents a condition 
which has been called grub worm hypertrophy, from the fact of its 
striking resemblance to large white grubworms, lying one on either 
side of the septum. On the lower turbinates will be seen a rounded 
whitish mass, with a raspberry-like outline of surface, presenting 
minute furrows and fissures crossing it in irregular lines. This same 
appearance is seen on the middle turbinated, although the masses are 
much smaller, and present an elongated spindle-like contour. 

The superior turbinated tissues may occasionally be seen by this 
examination, but are rarely the seat of any morbid process. 

A still further development of the hypertrophic process is occa- 
sionally recognized by the examination, in which the posterior ter- 
mination of the lower turbinated bones presents the appearance of 
large rounded masses with the same rugous surfaces, which more or 
less completely fill the oval openings of the posterior nares (see Fig. 
27) — a condition first described, I believe, by Lefferts and to which 
the name of posterior hypertrophy has usually been given by writers. 
Bigelow, in demonstrating the turbinated bodies, called attention to 
the fact that, if this tissue is artificially distended by a blowpipe, " a 
pouch-like process projects from the rear of the bone, increasing its 
length." 

Bigelow 's observation easily explains why these so-called "pos- 
terior hypertrophies" occur. 

So far our examination has shown us the existence of hyperemia 



78 



DISEASES OF THE NASAL PASSAGES. 



of the membrane, the amount of which has been recognized by the 
eye. The amount of true hypertrophy which exists in the mem- 
brane has not yet been ascertained. There is now to be thrown into 
the anterior nares a four-per-cent solution of cocaine by means of the 
spray apparatus, the effect of which will be to thoroughly expel the 
blood from the membrane. The action of the cocaine should be 
carefully watched, and the thoroughness of the application and the 
completeness of its action be awaited. When the membrane has be- 
come thoroughly exsanguinated, we shall find the whole of the nasal 
passages brought completely under observation, unless some condi- 




Fig. 27.— Large Masses of Hypertrophied Membrane on the Posterior Termination of the Lower 
Turbinated Bones, More or Less Completely Filling the Posterior Nares. 

tion other than the one under consideration exists to interfere with 
the inspection. We find now the lower turbinated bone covered with 
a soft, thick, somewhat velvety membrane, which adheres closely to 
it, and reveals the bony outline more or less completely, according to 
the extent of the structural thickness of the membrane. Now, if 
there were no hypertrophy existing in the mucous membrane, the 
lower turbinated bone would appear almost like a cord lying against 
the external wall of the nose, covered by a closely adherent, thin, 
parchment-like membrane, possessing a thickness not sufficient to 
mask the general contour of the bony structure beneath. If, how- 
ever, the membrane is the seat of connective-tissue hypertrophy, this 
will be recognized by the extent to which it does mask the normal 
bony contour. In front there will be a soft, rounded, cushion-like 
knob, as it were, grayish-white in color; it can be moderately in- 
dented by the probe, which in all cases should be used freely over 
its surface, in order to gain accurate knowledge of the extent of the 
hypertrophic process. Looking along this surface beyond the an- 
terior extremity, we shall find the membrane presenting, as a rule, 



HYPERTROPHIC RHINITIS. 79 

less evidence of thickening, both on inspection and to the impact of 
the probe, but still sufficient to give a rounded outline to the bone 
beneath. 

If now the head is thrown backward and the middle turbinated 
tissues are brought into view, they will be seen covering the bone 
somewhat closely, of the same general tint as the membrane below, 
but as a rule presenting also a thickened mass anteriorly, which 
here, instead of hypertrophy, assumes more of a polypoid appearance. 
The hypertrophy is of a somewhat myxomatous character, and hence 
the swelling is not so markedly reduced by the use of cocaine. The 
probe should be used here also to determine the character and loca- 
tion of the hypertrophic process. 

If now we examine posteriorly, the same appearances will present 
as were seen before the cocaine was applied, with this change, how- 
ever, that the swollen masses on the posterior terminations of both 
middle and lower turbinated bones present less prominently, and are 
smaller in size. Superficially, however, they show the same grub- 
worm-like membrane as before described. 

Treatment. — The first question which arises in the discussion of 
the treatment of this affection is as to the value of local applications, 
such as astringents, alteratives, and stimulants. That these have an 
effect in temporarily relieving the troublesome symptoms of the dis- 
ease, I think, no one will question, but when we consider what the 
morbid lesion is, namely, a deposit of connective tissue in the inter- 
vascular tissues, whereby the important functions of the membrane 
are hampered, I think that all must concede that a simple local ap- 
plication, by means of spray or douche, can have but a very ephem- 
eral effect. Furthermore, their efficiency is quite as great when 
applied at the hands of the patient himself as when applied in the 
office of the physician. There are certain remedies, then, whose 
action we all recognize, and whose aid we seek by directing that the 
patients shall make use of them in the intervals of their attendance 
upon office treatment. If there is much nasal stenosis with mucus 
accumulation in the upper pharynx, a cleansing wash is always grate- 
ful to the patient, and he should have it near him for frequent use, 
simply as a part of his toilet apparatus. With this we may combine 
both the cleansing properties of the alkalies with one of the simple 
astringents, such as : 

E Acidi carbolici, gr. iij. 

Sodii bicarb., gr. xij. 

Sodii biboratis gr. xxx. 

Glycerini, § ss. 

Aqua?, . . . . . . . ad § vi. 

M. ft. lotio. 



80 DISEASES OF THE NASAL PASSAGES. 

To this may be added a vegetable or mineral astringent, such as : 

]$ Acidi tannici, gr. x. to the ounce. 

Zinci sulphatis, " ij. " 

Aluminis, "v. " 

Zinci sulpho-carbolatis, " iij. " 

Zinci chloridi, ........ " i. " 

These are best used by the convenient little atomizer shown in 
Fig. 18, thus avoiding the inconvenience and possible dangers of the 
Thudicum nasal douche. In the absence of an atomizer, I think 
the simple device of insufflation of warm salt water from the hand 
may be safely recommended to the patients, when any comfort re- 
sults from the cleansing of the passages thereby secured. Snuffs, 
whether insufflated from the fingers or blown by an insufflating appa- 
ratus, possess no advantages over aqueous solutions. They simply 
call upon the mucous membrane for a sufficient amount of water to 
dissolve their efficient ingredient before they can exert any influence, 
unless we except those which are used for stimulating purposes, and 
here we have a method of local relief for such cases which is often- 
times of undoubted temporary benefit. There are certain remedies 
which, when applied to the nasal membrane, give rise to pain and 
irritation, for the time, followed by a more or less profuse watery 
discharge from the nose. Their first effect is rather distressing, the 
ultimate effect exceedingly grateful to the patient. The watery dis- 
charge which they excite seems, as it were, to unload the plethoric 
veins by this profuse exosmosis, which in its discharge seems to wash 
out the glands, and carry away a lot of surface debris, by which the 
membrane is for a time very markedly relieved, and the discomfort of 
the patient much alleviated. The ultimate effect, however, is of 
somewhat questionable advantage. Certain of the largely advertized 
catarrh snuffs sold in the drug stores act on this principle. The 
most notable of these remedies are perhaps bicarbonate of sodium, 
bromide of potassium, sanguinaria, galanga, etc. None of these 
remedies should be applied undiluted to the nasal mucous membrane 
in a state of hypertrophy, although all of them possess beneficial 
qualities in the atrophic form of the disease. The only advantage of 
powders is that they may be carried in the vest pocket and used at 
frequent intervals. The principle of their action is the same as that 
of the lotions above given ; hence we may prescribe them of the same 
proportions, substituting a bland, neutral powder for the water. If the 
stenosis in these cases is troublesome, I seo no objection to placing 
in the hands of the patient a two-per-cent solution of cocaine, with a 
small atomizer, by the occasional use of which he may give himself 
the temporary relief that this drug affords. 



HYPERTROPHIC RHINITIS. 81 

All of these remedies, it should be understood, are merely pallia- 
tive ; the permanent cure of these cases depends upon measures which 
will diminish hyperemia, remove structural hypertrophy, and restore 
the normal calibre of the passages. The object of treatment, it must 
be remembered, is not destruction of tissue, but its restoration to a 
healthy condition. Extensive sloughing, followed by cicatrization, 
might result in a condition quite as deleterious, or even more so, 
than the disease which it was originally designed to remove. The 
last stage of atrophy is really a stage of cicatrization. If this plan 
of treatment were carried too far, we might easily produce a condi- 
tion closely resembling an atrophic rhinitis in its advanced stages. 
The same objection lies with equal force against the various devices 
which were greatly in vogue some years since for wrenching away 
this hypertrophied membrane by means of forceps, or the canula 
scissors of A. H. Smith as described by Eobinson, and Woakes' 
nasal plough. It should be stated, however, that these devices have 
deservedly fallen into general disuse. Local astringents having failed 
to accomplish any notably good results in these cases, these harsh 
measures, above alluded to, were taken up and advocated for a while 
with considerable earnestness ; but the results of treatment proved 
disastrous in many cases, and search was made for still other medi- 
caments for controlling the disease. Naturally, the use of caus- 
tics was then taken up, and still with the idea, that the destruc- 
tion of tissue was the end to be accomplished, for we early rind 
recommended the most powerful chemical agents, such as Leyden 
paste, Yienna paste, and nitric acid, together with the galvano- 
cautery. Some years since, in discussing this question, I entered 
my protest against these measures, claiming that better results would 
be secured by milder treatment in cases in which the object was merely 
to reduce hypertrophic conditions, and then advocated the use of gla- 
cial acetic acid. Since that time, I have abandoned the use of this 
agent for one possessing more valuable properties as a caustic, 
namely chromic acid, on the ground that these powerful agents were 
apt to do harm rather than good, on account of the difficulties in 
limiting their application. 

It cannot be too forcibly emphasized, I repeat, that the object of 
treatment should not be to destroy tissue, but to constrict the blood- 
vessels, diminish the nutrition, and thus counteract hypertrophy. 
We know that the deep cavernous layer, by furnishing an increased 
blood supply, is the primary seat of the trouble. No destructive 
agent, applied as we are in the habit of using them in treating the 
nasal mucous membrane, can cause necrosis of more than the super- 
ficial epithelium, and possibly, to a very slight degree, of the sub- 
6 



82 DISEASES OF THE NASAL PASSAGES. 

mucosa ; it does not affect the deep or cavernous layer, which is the 
one chiefly concerned. To what, then, is the beneficial action of a 
caustic application due, for it certainly is of great benefit? 

Until quite recently caustic applications were effective simply by 
the contraction of the superficial slough formed. By this contraction 
the calibre of the venous sinuses was diminished, and the walls of 
the vessels were enabled to regain their proper tone. Since the dis- 
covery of the wonderful power which cocaine has of contracting blood- 
vessels, caustic applications have been much more efficient. The 
ordinal procedure is, by an application of cocaine, to deplete the 
vessels by diminishing their calibre ; then by applying caustic to the 
most prominent points, we pin down this already contracted tissue by 
the formation of a superficial slough, maintain the vessels in a state 
of contraction until they can regain their normal tonicity, and thus 
control nutrition. 

What agent shall we use to accomplish this purpose? Shall we 
resort to the various chemical agents, or to the potential cautery? 
The effect is the same in either case. For a considerable time I 
have used chromic acid to the exclusion of all other agents. 




Fig. 28.— The Author's Chromic-Acid Applicator. 

The extreme nicety with which it can be applied, without cumber- 
some or expensive apparatus, its efficiency, and the absence of un- 
pleasant effects following its intelligent use, have been sufficient to 
commend it to me, to the almost total exclusion of other agents. It 
has been claimed that cicatrices result from its use, but I have never 
observed them. It seems almost paradoxical to control a morbid 
process by a destructive agent, but at the present stage of our thera- 
peutic resources we possess no better method. 

The special manner in which it should be used is as follows : A 
small, slender probe, such as is shown in Fig. 28, is first dipped in a 
little mucilage, and then four or five of the slender acicular crystals 
of the acid are taken up upon it, and held over a flame until they are 
fused into a small tear, as it were, on the end of the probe, which on 
cooling will present a small, solid red bead of amorphous chromic 
acid, which can be easily manipulated and carried to the part, already 
anesthetized and exsanguinated by the application of cocaine, which 
it is desired to medicate, without danger of injuring healthy tissue. 



HYPERTROPHIC RHINITIS. 83 

The galvano-cautery, since its use was first advocated by Middle- 
dorpf, has come into very extensive use, and is warmly advocated by 
Mackenzie, Moldenhauer, Sajous, Lennox Browne, Seiler, Schech, 
Robinson, Moure, and others. All of these writers give it preference 
over other methods, and many of them have presented us with inge- 
nious forms of batteries which are claimed to possess certain advan- 
tages. 

A smaller number of authorities, while recommending it, fail to 
give it the first place as a caustic agent, such as Woakes, Cohen, 
Wagner, and others. I think I do not overstate the case when I say 
that the potential cautery possesses no advantages over the chemical 
cautery if properly and deftly applied, and with a nice appreciation 
of what is to be accomplished. The battery is a large, unwieldly, 
cumbrous apparatus, excedingly liable to get out of order, and a 
constant source of annoyance by its liability to fail us just when it is 
most needed, from short circuiting, polarization, or, more likely still, 
some hidden and undiscoverable fault which hampers its working. 
In treating hypertrophic rhinitis, this somewhat complicated appa- 
ratus is used to develop a certain amount of heat in a small platinum 
electrode, for the purpose of endowing the electrode with a moderate 
amount of destructive potency. Now, as we have already shown, the 
amount of absolute destruction which we wish to accomplish is very 
limited. It would seem, therefore, that we resort to a somewhat 
irrational process for accomplishing all this, when a few crystals of 
chromic acid, fused on the end of a probe, will accomplish the same 
purpose equally well. In condemning the use of the galvano-cautery 
methods, I do not attempt to criticise the results thereby obtained. 
There can be no question as to the success of the so-called galvano- 
caustic treatment. I merely say that we put ourselves to a vast deal 
of unnecessary trouble and inconvenience when we use this instru- 
ment. I think, however, another point worthy of consideration is 
that, in introducing the cautery electrode into the nose, and develop- 
ing in it a high degree of heat, we do incur a certain amount of risk. 
Most writers recognize this, and make special allusion to the violent 
reaction that may set in following its use, giving rise to an acute 
rhinitis, a distressing neuralgia, an acute dermatitis, or even an 
attack of facial erysipelas, as I have seen in three cases — complica- 
tions which rarely, if ever, attend the proper manipulation of a chem- 
ical agent. Notwithstanding what has been said, the galvano-cautery 
is an exceedingly attractive method of treating affections of the nasal 
cavities, and undoubtedly will always remain a popular instrument. 
I have had personal experience with a number of different forms of 
cautery batteries, and find it difficult to designate any particular 



84 



DISEASES OF THE NASAL PASSAGES. 



apparatus as offering special advantages. Of the two forms of 
galvano-cautery batteries, viz., the chemical and the storage, I think 
the preference usually will be given to the former, in that the charg- 
ing of the storage battery requires either a somewhat elaborate appa- 
ratus in one's office, or the inconvenience of sending it to the electri- 




c B 



Fig. 29.— Galvano-Cautery Handle with Flat Electrode for Use upon the Turbinated Tissues. 

cian for restorage. Of the dip-plate batteries, perhaps none is better 
than the inexpensive instrument manufactured by Meyrowitz, for, 
although somewhat bulky in size, it is simple, and not especially 
liable to get out of order. The cautery handle should be light and 
easy of manipulation. In Fig. 29 is shown perhaps as efficient an 
instrument as any other. It is mounted with a flat electrode, suitable 
for use upon the turbinated tissues. Other forms of electrodes, de- 
signed to fulfil special indications, will be selected according to each 
operator's preference. Various forms of these are 
shown in Fig. 30. The electrode should be bent at an 
angle of forty -five degrees with the handle, thus en- 
abling the operator to follow the platinum tip closely 
with his eye, in order that the cauterization shall al- 
ways be accomplished directly at the summit of any 
projecting mass of hypejrtrophied tissue. The plati- 
num tip used should, as a rule, be quite small, and in 
making the application a limited surface only should 
be burned over at each sitting. Furthermore, it is 
well to keep up a slight motion, if possible, in the in- 
strument after the current is turned on, which should 
always be done after it is carried to the desired local- 
ity, and shut off before it is withdrawn, in order that 
the electrode may cool, and thus healthy tissue in 
other parts of the nostril escape injury by the instru- 
ment on its removal. The object of the slight motion 
recommended is to prevent the electrode from adher- 
ing to the burned tissues, for when this occurs its 
withdrawal is usually attended with a tearing away, 
by which the blood-vessels are ruptured, and hemor- 
rhage ensues. The degree of heat in the instrument, 
when feasible, should be regulated. This is not possi- 
ble, however, in all cases. A red heat is preferable, as there is dan- 
ger of the extreme white heat burning more extensively than may be 



Fig. 30. — Nas al 
Electrodes. A, 
Bulb - pointed ; 
B, knife ; C, 
curette; Z>, 
point. 



HYPERTROPHIC RHINITIS. 85 

desired. It is often recommended to use a cautery knife, by which 
the surface of the membrane may be incised as it were, thus burning 
a furrow well into the turbinated tissues. I think, however, as a 
rule, a superficial burning, producing a slough such as has been de- 
scribed in connection with chromic acid, will be all that is sufficient, 
using for this purpose a small flat electrode. A twenty-per-cent 
solution of cocaine, of course, should be used in the manner already 
described in connection with chromic acid. After the burning, the 
cavity should be repeatedly washed out with a cleansing spray, thus 
cooling the membrane and allaying such irritation as may be caused 
by the application. 

As a rule, caustic applications are not specially painful, and yet, 
in many cases, notwithstanding the use of cocaine, a certain amount 
of pain referable to the burned surface will be produced, while in 
others severe neuralgia will be caused as the result of the caustic 
acting on the terminal filaments of the nerves. When this occurs, 
it is well to allay it immediately, otherwise it may persist many 
hours. For this purpose nothing is better than the application of 
dry heat, which is usually accomplished by holding a towel against 
the hood of the rhinoscope or the chimney of a coal-oil lamp for a 
few seconds, and applying it to the face, changing the towel fre- 
quently. This is simple and perhaps more convenient than the hot- 
water bag or the Japanese pocket stove, either of which may be used. 
The caustic applications should be repeated at intervals of a week or 
ten days. 

These measures will be fully equal to the reduction of chronic 
hyperemia with hypertrophy of the nasal mucous membrane, where 
no complications exist. If the cause of hypertrophic rhinitis is a 
deflected septum, any measure for the reduction of the hypertrophic 
process will give but temporary relief, while the exciting cause re- 
mains. 

A condition is not infrequently found in these cases which has 
already been alluded to, and which consists of an hypertrophy of 
the posterior extremity of the lower turbinated bone. Cauterization 
does not reduce these masses, and surgical interference is always nec- 
essary. 

For the removal of this redundant tissue we possess no device 
which is so efficient as the cold wire-snare ecraseur, which has come 
so largely into use of late for the removal of growths, hypertrophic 
masses, etc., in the nasal passages. To the late Dr. Jarvis is un- 
doubtedly due the credit of having introduced the principle of ecrase- 
ment, as applied to nasal growths, or certainly to have demonstrated 
its great value, when he devised the very ingenious and yet simple 



86 



DISEASES OF THE NASAL PASSAGES. 



instrument which is known as Jarvis' snare (shown in Fig. 31). The 
wire to be used in this instrument is the highly tempered steel piano 
wire, the No. 5 being perhaps best adapted for all purposes. The 
working of the instrument is obvious. The two ends of the wire are 
passed up through the inner tube, and firmly fastened to 
the projecting pins on the outer tube, leaving a loop pro- 
jecting from the distal extremity, which is drawn within 
the canula by turning the nut, and thus carrying the 
outer tube before it. 

One great advantage of this instrument consists in 
the substitution of the principle of ecrasement for that 
of snaring, whereby the growth is separated without in- 
juring healthy tissues, and at the same time the danger 
of hemorrhage notably diminished. Another, and very 
important feature of it, consists in the use of the steel 
piano wire, which furnishes a loop of such strength and 
resistance, that it can be readily carried into the nasal 
cavity and fitted about a growth without yielding or 
bending, thus affording a facility in manipulation, which 
is in no manner equalled by the soft annealed wire loop. 
In dealing with the above condition of posterior hy- 
pertrophy the Jarvis instrument is to be preferred. This 
is mounted with a loop, which an examination of the 
mass has shown to be sufficiently large to embrace it, 
and is then introduced through the nares until the end of 
the loop passes the end of the turbinated bone and is 
free in the upper pharynx. The loop, having been bent 
slightly to one side before entering the nares, will, by 
its own elasticity, slip over the mass, when it can easily 
be drawn into place and the tumefaction cut through. 
Of course, there is liable to be a considerable hemorrhage 
as the result of this procedure, but if the operation be 
done slowly, a half hour or even an hour being consumed, 
it may often be done without loss of blood. If, how- 
ever, hemorrhage does occur, a plug of absorbent cotton 
can easily be passed back and wedged between the cut 
surface and the septum, and allowed to remain until the 
following day, if necessary. The relief attending this operation is 
immediate and striking. The accompanying illustration, Fig. 32, 
gives a. side view of this posterior hypertrophy. It is a drawing by 
Dr. Jarvis of a morbid specimen in his possession. There is also 
shown in the plate the snare in position for severing the mass. 

A condition not unlike this at the posterior termination of the 




FtG. 31.— Jarvis' 
Wire - Snare 
ficraseur. 



HYPERTROPHIC RHINITIS. 87 

lower turbinated bone is frequently met with, though in a far less 
degree, at the anterior termination of the same body. This consists 
of a rounded, puffy -looking mass, which encroaches on the lumen of 
the anterior nares, more or less completely filling it, and serving to 
obstruct materially the entrance of air. 

Hypertrophy of the membrane of the middle turbinated bone occurs 
in a large majority of cases anteriorly. It is of a loose structure, and 
assumes a myxomatous character presenting to the eye a bluish-gray 
appearance, between the nasal mucous membrane and a nasal polyp. 
This may develop on an otherwise healthy turbinated bone, or the 




Fio. 3-2.— Lateral View of Posterior Hypertrophy of the Mucous Membrane of the Lower Turbinated 
Bone, with Jarvis' Snare in Position for Section. 

bone itself may become enlarged and unrolled, as it were, on itself, 
in such a way as to present a large shuttle-like prominence, project- 
ing downward and inward, thus encroaching upon the normal lumen 
of the cavity. No hesitation should be felt in removing this mass, 
and we possess no method better than the use of the steel wire snare. 
The steel wire loop possesses sufficient firmness to enable the manip- 
ulator to carry it well over the mass, which can be then easily severed. 
In many cases a portion of the bone is removed with the thickened 
membrane, which I think is always permissible, as probably the 
deformity of the bone has much to do with the development of the 
hypertrophy. The snare, I think, should always be used in these 
cases, as caustics are inadequate to their destruction. The galvano- 
cautery loop may be used, but the cold wire is more easily manipu- 
lated and the operation is completed more rapidly. 

Hemorrhage as the result of operations on the middle turbinated 
bone is comparatively rare, although three cases of operation in this 
region at my hands have been followed by this accident; the 
hemorrhage being exceedingly intractable, plugs not only being 



88 DISEASES OF THE NASAL PASSAGES. 

rendered necessary, but their removal not being feasible until the 
third day. 

In the treatment of all cases of catarrhal disease, special stress 
should be laid on the enforcement of those general hygienic measures 
which have already been fully discussed in the chapter on taking 
cold. A catarrhal process is kept up oftentimes and aggravated by 
the same conditions which give rise to the phenomenon of taking 
cold. The same general hygienic laws which we have already dis- 
cussed under the heading of prevention of cold should be specially 
enforced. 






CHAPTER X. 

PUKULENT KHINITIS OF CHILDKEN. 

This expression is used to describe an affection which is met with 
exclusively in children, and which is attended with a purulent dis- 
charge from the nasal mucous membrane. 

While recognizing the existence of the acute purulent rhinitis in 
new-born children, as dependent, probably, on infection from the 
vaginal passages of the mother, we meet with a large number of cases 
which commence in the earlier years of childhood, in which the 
disease pursues an essentially chronic course and in which a purulent 
discharge is the prominent feature. It is purely local in character, 
dependent on no constitutional dyscrasia, and consists essentially in 
an increased secretion of mucus in the earlier stages, together with 
a rapid desquamation of epithelial cells, and in from five to ten years 
develops finally into what is known as atrophic rhinitis. The 
disease, in fact, is the first stage of so-called dry catarrh or ozaena. 
From a clinical point of view, it is a very noticeable fact, in patho- 
logical processes involving mucous membranes certainly, and probably 
all tissues of the body, that in youth the epithelial structures are 
especially liable to become the seat of diseased action, whereas in 
adult life this tendency seems to disappear, and in place of it there 
obtains a tendency to the involvement of the connective-tissue 
structures. 

Now, this peculiar tendency in childhood shows itself in a notable 
activity in the development of the epithelial cells, under the stimula- 
tion of any of those causes whose agency we recognize in the pro- 
duction of inflammatory processes. Furthermore, this activity in 
epithelial development may result in two distinct processes. In the 
one, we find the new epithelial cells building themselves upon the 
parent structures and remaining a permanent element in the tissue. 
In other words, a true epithelial hypertrophy takes place and results, 
in the case of the tonsillar gland for instance, in an hypertrophied 
tonsil. In another case, a rapid process of desquamation sets in. 
Now, as to why these new cells in the one case build themselves upon 



90 DISEASES OF THE NASAL PASSAGES. 

the membrane, and in the other case are thrown off, I do not suggest 
a reason. Certainly it is not dependent on any constitutional 
dyscrasia which destroys the power of the individual cell to maintain 
its identity as an integral part of the membrane, for, if there is any 
notable dyscrasia in these cases, it would seem to be more marked in 
those instances in which hypertrophy takes place, rather than the 
desquamative process. An ordinary acute inflammation of the 
mucous membrane of the nasal passages in a child does not result 
in congestion of the mucous membrane involving the turbinated 
tissues. If a child has an attack of what is called cold in the head, 
in a majority of instances it is an acute inflammation, with swelling 
of the glands of the vault of the pharynx, producing more or less 
complete nasal stenosis, from occlusion of the posterior nares. In 
the less frequent cases, it is the mucous membrane lining the nasal 
chambers. When this occurs, we notice this susceptibility already 
spoken of immediately showing itself, and the superficial layer of the 
mucous membrane, the epithelial layer, becomes the seat of marked 
morbid activity, differing essentially from the process which occurs 
in adult life. Now, with the first attack of a cold, the symptoms may 
not differ in a very marked manner from a cold in adult life, but as 
these attacks recur there sets in a notable tendency to a rapid prolif- 
eration of epithelial cells, which, being thrown off in connection with 
an excessive mucous discharge, give rise to a muco-purulent secre- 
tion. These repeated attacks of the acute disease finally develop into 
a chronic rhinitis, characterized by no very noticeable nasal stenosis, 
but by a more or less profuse purulent discharge, and the disease 
which is the subject of this chapter is established. Commencing, as 
a rule, at from three to five years of age, it runs a somewhat slow 
course of from ten to twelve years, when it develops into an atrophic 
rhinitis. 

The morbid process, from the beginning to the end of the disease, 
is identical in all its features, except as to the degree of activity. It is 
a catarrhal process in the first year, and it is a catarrhal process 
always. The deeper tissue structures are but slightly involved, and 
the surface layer becomes the site of but one form of diseased activity, 
and that consists of an epithelial desquamation together with muco- 
purulent discharge. Ulceration of the soft parts, or necrosis of the 
bone beneath, are never, under any circumstances, a part of the pro- 
gress of the disease. 

In some cases, the disease commences in the first year of life, 
although in these cases there is no tendency to a more rapid devel- 
opment of the later symptoms. As a rule, the purulent character of 
the discharge is maintained until about the fourteenth or fifteenth. 



PURULENT RHINITIS OF CHILDREN. 91 

year, although, in one case which has come under my observation, 
the atrophic stage with crust formation developed as early as the 
eighth year of age. 

Etiology. — It is a very common assertion that atrophic rhinitis 
and ozsena are dependent on the scrofulous diathesis. Of course, this 
assertion would necessarily include this dyscrasia as the cause of the 
disease in question. In my own experience, children affected with 
this affection present a picture of rugged health which would scarcely 
warrant the suspicion of any constitutional dyscrasia, nor can syphilis 
be said to have any influence, either in producing or in indirectly caus- 
ing the disease. The clinical history of syphilis presents a series of 
symptoms of a totally different character. Many forms of catarrhal 
disease in children have their origin in an attack of scarlet fever, 
measles, or some other of the exanthemata. My experience is that a 
purulent rhinitis rarely commences in this way. On the contrary, 
the catarrhal affections which have their origin in a febrile attack are 
characterized by hypertrophic changes. I know of no assignable 
cause for the disease, other than taking cold, and this we explain by 
the neglect of the ordinary hygienic rules of proper living, as already 
discussed in a previous chapter. 

Symptoms. — The prominent symptom of the disease is a muco- 
purulent secretion usually of a bright yellow color, and having 
its source from both nostrils. This is expelled in considerable quan- 
tities into the handkerchief, and also makes its appearance about the 
nostrils, constituting what is often called a " dirty -nosed" child. 
There is no especial obstruction to the nasal passages, except as the 
result of the accumulation and drying of the secretion about the 
anterior nares. The discharge is generally through the nostrils, 
although more or less of it is drawn down or makes its way into the 
fauces. During sleep the secretions are apt to accumulate to such an 
extent as to cause mouth breathing. The child, of course, is liable 
to take cold, during which there are exacerbations, and the attack is 
attended with a more profuse discharge containing a large amount of 
serum. During the exacerbation sneezing is a rather prominent 
symptom, though at other times it is not present, the sensibility of 
the nose being diminished rather than increased. Fetor, so promi- 
nent a symptom in the atrophic stage of the disease, is never present 
while the discharge remains fluid and moist. 

Diagnosis. — A rhinoscopic examination anteriorly reveals the 
mucous membrane covering the turbinated bones somewhat swollen, 
and of a reddish tint, with perhaps the appearance of a mild subacute 
inflammation, but rarely presenting the active turgescence and bright 
red appearance of an acute inflammatory process. Coating the faces 



92 DISEASES OF THE NASAL PASSAGES. 

of both the lower and middle turbinated bodies will be seen flakes and 
strings and even large masses of bright greenish-yellow muco-pus, 
in a semi-fluid state. An examination of the fauces will show muco- 
pus coating the posterior wall of the pharynx and trailing down its 
wall in stringy masses. This condition, however, it should be 
remembered, is also seen in connection with disease of the adenoid 
glands of the vault of the pharynx. An examination of the vault of 
the pharynx, however, will usually reveal whether any morbid con- 
dition exists there to account for this post-nasal discharge. 

The diagnosis, however, is not based on the rhinoscopic exami- 
nation alone, but can easily be made both from the objective 
symptoms and by elimination. A purulent discharge is met with in 
children as the result of strumous ulceration and necrosis, the 
presence of foreign bodies, blennorrhcea, diphtheria, and the late 
stages of acute rhinitis met with in connection with the exanthemata. 
If there are any other causes, they are of exceeding rare occurrence. 
Syphilitic or scrofulous disease gives rise to an exceedingly offensive 
discharge of pus, mingled with blood, from one or both nostrils, but 
it is accompanied by so many marked symptoms of blood poison- 
ing that a mistake in diagnosis need not be made. A foreign body 
in the nose gives rise to a purulent discharge, as a rule, from but 
one nostril. A purulent rhinitis invariably involves both sides. 
Furthermore, inspection and examination with a probe should always 
eliminate this source of error. Blennorrhcea occurs as a rule in the 
new-born child, and is characterized by such activity of the morbid 
process, both as regards the amount of discharge and the swollen 
condition of the membrane, as to render its recognition comparatively 
simple. Furthermore, the conjunctival membrane rarely escapes the 
blennorrhceal poison. Purulent discharge from the nose in connection 
with diphtheria and the exanthemata need not, of course, be con- 
founded with the disease under consideration. 

Pkognosis. — These cases, as before stated, run a course of from eight 
to ten years' duration, the symptoms developing slowly and the 
discharge increasing in amount, showing a tendency to accumulate in 
the passages and becoming thicker and more inspissated in character 
as the years go on. During this time the mucosa proper becomes 
the seat of no marked changes othqr than a moderate congestion of 
its blood-vessels. The epithelial layer, on the contrary, is slowly but 
surely wasted, from the loss of its superficial layers, and becomes 
abnormally thin, while at the same time the mucous glands and 
follicles become, to an extent, involved, so that they, also becoming 
subjected to the desquamative process, lose a certain amount of 
their lining epithelium. Hence, it will be easily understood how in 



PURULENT RHINITIS OF CHILDREN. 93 

the later years of the disease the prognosis becomes somewhat 
unfavorable as regards an ultimate cure. In earlier years, however, I 
believe if proper treatment is administered, and carried out with 
sufficient persistence and attention to detail, that we may hope not 
only to arrest its further progress, but ultimately entirely to cure the 
affection. 

Treatment. — The first step in treatment will consist in the use of 
some simple lotion, by which the pus discharge may be thoroughly 
removed from the cavity and the surface of the membrane thoroughly 
cleansed. For this purpose any simple alkaline wash will be found 
efficient, to which may be added a small amount of carbolic acid or 
listerin. 

Dobell's solution answers an excellent purpose, or perhaps better 
still we may use one of the following formulae : 

R; Listerin, 3 ss. 

Sodii biboratis, I ss. 

Glycerini \ . . 3 vi. 

Aquae ad § vi. 

Or, 

R, Thymol, gr. x. 

Sodii chloridi, 3 ss. 

Sodii benzoatis, gr. xx. 

Aqua', ad 3 vi. 

These cleansing lotions are best used by means of a small single- 
bulb atomizer, such as is sold in the drug stores, the best of which 
perhaps is that shown in Fig. 18. This should be used at the 
commencement of treatment at least three or four times daily, the 
wash being thrown into both nostrils and the child being taught to 
cleanse the passages as thoroughly as possible by blowing the nose 
immediately after. In lieu of the atomizer an ordinary ear syringe 
may be used, but as a rule I think the atomizer preferable. 

After the membrane is thoroughly cleansed, an astringent should 
be used in the same manner, by means of the syringe or atomizer, 
preference being giving to those agents which possess the property of 
controlling cell jjroliferation. 

For this purpose we may use one of the following : 

3$ Zinci sulpho-carbolat., gr. xx. 

Hydrarg. chloridi corros., gr. A 

Aqua?, ad 3 iv. 

M. 

Or, 

R Acidi borici, " ij. 

Aquae, , . . . ad 3 iv. 



94 DISEASES OF THE NASAL PASSAGES. 

To any of the above there may be added, with benefit, one of the 
simple astringents, or they may be used alone. 

The effect of these agents should be noted, and a change in the 
special drug employed occasionally made, as it would seem that 
even the best of local remedies lose to a certain extent their effect 
from long usage. Occasionally good results will be obtained by the 
use of ordinary skimmed milk, or, even better still, buttermilk. These 
may be used pure or in combination. To equal parts of lime water 
and buttermilk may be addded sulpho-carbolate of zinc of a strength 
of two grains to the ounce. Permanganate of potash is a remedy of a 
certain amount of value in controlling cell proliferation, and may be 
often used with benefit, in the strength of three to five grains to the 
ounce. 

Watery solutions are to be preferred, in the treatment of these 
cases, to other forms of medication. Inhalations and vapors are 
probably without effect. Powders, however, because of their con- 
venience may be used with benefit, the patient being directed to carry 
a box in his pocket for frequent application. 

In addition to local treatment, general hygienic measures are 
especially indicated in these cases, not perhaps from any features be- 
longing to the disease itself, but rather on account of the tender age 
of the patients with whom we have to deal and their peculiar vulner- 
ability to changes of temperature. These measures are embraced 
briefly under the injunction that a daily cold sponge bath to the waist 
should be used and absolutely pure all-wool flannels worn next to 
the skin in summer and winter; together with the other general 
directions as to sleeping apartments, clothing, exercise, etc., which 
have been given in the chapter on taking cold. 

Internal medication is not indicated, and yet it has been my habit 
for some years past, perhaps as a matter of routine, to administer 
cod-liver oil, which seems to exercise a certain amount of controlling 
influence on the disease. 



CHAPTER XL 

ATEOPHIC KHINITIS. 

It will be noticed that we embrace all forms of catarrhal inflam- 
mation of the nasal mucous membrane practically under the two 
heads, atrophic and hypertrophic. The distinctive character of 
atrophic rhinitis was first pointed out by myself in a paper read 
before the Seventh Session of the International Congress of London 
in 1881. The view there laid down I still regard as the true expla- 
nation of the development of the disease. Commencing in a desqua- 
mative inflammation, a purulent rhinitis is set up, which constitutes 
the early stage of the disease under consideration. 

The progress of the disease as a purulent rhinitis has already 
been fully described. In that chapter it was stated that the predom- 
inating morbid condition consisted in the desquamation of epithelium 
from the surface of the mucous membrane. Now, so long as this 
desquamation is confined to the superficial epithelial cells, we can 
easily understand that the disease is attended with a thin and fluid 
muco-purulent discharge. Naturally, however, the morbid process 
will not confine itself to the superficial layer of the membrane, and 
the glands are rapidly involved ; the muco-purulent discharge assumes 
a more inspissated character, and clings to the turbinated bodies. 
As the disease progresses, the turbinated bones themselves become 
atrophied. As the result of impeded circulation, due to the adhering 
crusts already described, the circulation of the blood in the deep layer 
of the membrane is so far arrested as to rob the bone itself of its 
normal nutrient blood supply, thus causing an atrophy, by which 
eventually the bones disappear more or less completely from the 
nasal cavity, leaving only small and scarcely recognizable ridges on 
the outer wall. We have here, I think, a rational theory of the 
development of purulent rhinitis, and ultimately of atrophic rhinitis, 
which harmonizes fully with the clinical history of the disease. 

We have thus established, under the name of atrophic rhinitis, 
a disease which probably comprises a large number of the cases which 
have heretofore been embraced under the general term of ozsena. It 



96 DISEASES OF THE NASAL PASSAGES. 

may be repeated, in this connection, that this term is one used to 
describe a symptom, and not a disease, and by earlier writers has 
been used to describe all diseases of the nasal cavity characterized by 
an offensive discharge and a fetid odor. With our increased knowl- 
edge of intranasal disease and the advancement in our methods of 
diagnosis, the term ozsena, as describing any definite form of nasal 
disorder, of course, disappears from our literature. 

In brief, the changes consist in an atrophy of the mucous mem- 
brane, in which the morbid process is not due to a connective-tissue 
hypertrophy encroaching on the glandular structures of the membrane, 
but rather to the transformation of epithelial structures into inflam- 
matorj- corpuscles, together with an active epithelial desquamation 
from the surface of the membrane and from the lining of the acini. 

The follicles are surrounded by heaps of lymph corpuscles, but 
there is no evidence of transformation of these corpuscles into 
connective tissue, showing us that the inflammatory process is most 
marked in the neighborhood of the acini, but that it does not develop 
into a hyperplastic process. The morbid changes are, therefore, 
atrophic from their outset, and bear no relation whatever to the 
hypertrophic form of the disease. 

I am cognizant of no other investigations of like character, made 
on the living subject, although Frankel, Gottstein, Krause, Hartmann, 
and Habermann have all made microscox)ical study of the pituitary 
membrane in this disease, from the dead subject. The results of 
their investigations do not differ materially from my own. 

Frankel finds the lesion to consist essentially in the disappearance 
of Bowman's glands, the mucous glands of the lower turbinated bone 
remaining unchanged. Gottstein finds thickening of the connective 
tissue about the glands, with cloudiness of the epithelial lining. 
Krause finds a fatty degeneration, both of the mucous membrane and 
of the gland epithelium. Habermann believes the lesion to consist of 
a fatty degeneration of the gland epithelium, not alone of Bowman's 
glands, but of the acinous glands, thus partially coinciding with 
Krause. 

These views, it seems to me, are important, as affording us a prob- 
able explanation of the epithelial desquamation which characterizes 
the earlier stage of atrophic rhinitis, for, although my own studies 
fail to reveal evidences of this fatty degeneration, some explanation 
was needed to account for the desquamative process. If this fatty 
degeneration is found in a large number of cases, we need seek no 
further for a cause for the desquamation. 

Etiology. — We have already discussed the question of causation 
of purulent rhinitis, and this disease I believe to be, in every case, a 



ATROPHIC RHINITIS. 97 

cause of or the primary stage of the atrophic form. Allusion has 
already been made to the statement that atrophic rhinitis develops 
as a later stage of the hypertrophic form. Frankel, as before stated, 
was the originator of this idea, which has been followed very 
generally by subsequent writers, who all, however, content themselves 
with accepting Frankel' s original view, without stopping to question 
seriously the grounds on which it was based. Furthermore, an 
examination of their writings shows a striking absence of careful 
clinical observation to establish the teaching. The only clinical 
support that I have been able to discover, is the observations of 
Wagner and Schafl'er, the one having discovered this change to have 
taken place in a child of fourteen at the expiration of about six 
months, while the latter asserts that it takes place only after the 
expiration of ten years or more. 

I have studied my own cases very critically, and I find it a uni- 
versal, general rule, that purulent rhinitis is a disease of childhood, 
and atrophic rhinitis of adult life; that purulent rhinitis develops 
into atrophic rhinitis very rarely later than the twentieth year, and 
in the majority of cases earlier than the sixteenth; and, furthermore 
I have failed to discover any evidence that the hypertrophic form of 
the disease had ever existed before the patient came under my care. 
Now, there can be no question but that a large number of our cases 
of hypertrophic rhinitis come under treatment between the ages of 
twenty -five and thirty-five. If it is possible that this disease can 
result in the atrophic form in six months according to Wagner, or in 
ten years according to Schaffer, our clinical records certainly would 
show some evidence of it. I have never seen a case of atrophic rhini- 
tis which developed its atrophic symptoms later than the twenty- 
fifth year. 

Zaufal is alone in the view that atrophic rhinitis or ozsena is 
due to congenital deficiency in the turbinated bones. This theory is 
based on careless observation, for the atrophy of the turbinated 
bones occurs only in the late stages of the disease, and is rarely met 
with before puberty. Zuckerkandl finds in an examination of two 
hundred and fifty -two skulls of children no single case of congenital 
atrophy. Chatellier believes the atrophy of the turbinated bones to 
be due to a rarefying osteitis. Gelle, on the other hand, does not 
believe there is an osteitis, but refers the atrophy to interference with 
nutrition. 

Chatellier' s idea naturally suggests a general dyscrasia, whereas, 
as already stated, I think these cases are rarely, if ever, attended by 
any evidence of impaired general nutrition. Gelle, however, would 
seem to have arrived at somewhat the same conclusion as I have. 
7 



98 DISEASES OF THE NASAL PASSAGES. 

What has been said as to the causation of purulent rhinitis, ap- 
plies of course to the atrophic form of the disease. In the chapter 
on the former, the statement was made with marked emphasis that 
atrophic rhinitis bore no possible relation to syphilis in any of its 
stages or manifestations. The same broad statement may be made 
in regard to tuberculosis and scrofula, and yet we find Schaffer mak- 
ing the statement that in one hundred and nineteen cases he found 
ninety-nine of strumous and twenty of syphilitic origin. In two 
cases the complaint was distinctly due to hereditary syphilis ; while 
Wyss makes the statement that more than half of his cases of ozsena 
had a tuberculous history, but he found very few cases complicating 
phthisis. By the term ozsena he excludes all cases of syphilitic or 
carious disease of the nose. 

Symptomatology. — The symptoms which characterize the disease 
are the direct result of the apparent increase of secretion, and of the 
impairment of function of the mucous membrane. On account of the 
limited amount of serous exosmosis, the discharge becomes so thick- 
ened that it lodges within the cavity, and crust-formation becomes 
the prominent symptom of the disease. The presence of these crusts 
in the nasal cavity gives rise to more or less irritation, and occlusion 
of the nares results. 

The development of fetor soon follows and always constitutes the 
most prominent and distressing feature of the disease. Fournier 
believes the odor is due to a specific secretion of the glands of the 
pituitary membrane, likening the fetid odor of ozsena to that which is 
occasionally observed in connection with the feet. This is ingenious, 
but I believe it is a universal rule that a fetid secretion does not occur 
in nature. An excretion may be fetid, but never a secretion. 

Epistaxis occasionally occurs as the result of the erosions pro- 
duced by dry incrustations, especially on the septum. These ero- 
sions, it should be stated, are of a trivial character and never, under 
any circumstances, develop into anything resembling an ulcerative 
process, although they may occasionally develop into small perfora- 
tions of the cartilaginous septum, leaving permanent communication 
between the two sides. Mackenzie explains these perforations by 
the habit of picking the nose, which patients resort to in order to 
remove the accumulated crusts. 

Dryness of the pharynx becomes a prominent symptom of the 
disease very early in its history, and the lower, pharynx also presents 
a dry, glazed appearance, and swallowing becomes somewhat diffi- 
cult. There is more or less irritation of the larynx and bronchial 
tubes. Hoarseness is often present, and impaired vocal function 
alwavs. 



ATROPHIC RHINITIS. 99 

A form of laryngitis has been described by writers, notably 
Lennox Browne, characterized by the formation of dry crusts in the 
larynx and trachea. The implication seems to be that a diseased 
condition really exists in these parts, but it is difficult to determiDe 
any notable morbid lesion here, and I should rather lean to the view 
that it is purely a symptomatic affection. Spasm of the glottis, of a 
very distressing character, I have met with in connection with atro- 
phic rhinitis, in young women of highly nervous organization, and 
in men in vigorous health, with no suspicion of neurotic tendencies. 
In these cases it has disappeared upon directing vigorous measures 
to the nose. Its occurrence can be explained only by the presence of 
inspissated mucus or pus in the larynx acting as a foreign body. 

Moderate impairment of hearing occurs in the later stages of this 
disease in probably a large proportion of cases, while a graver form 
of deafness is not an infrequent complication. Wyss, of Geneva, in 
an examination of sixty cases of the disease, found ear trouble in 
forty -seven, including, probably, all cases of moderate diminution of 
hearing distance. Burnett, of Philadelphia, found an atrophic con- 
dition of the nasal mucous membrane in fourteen and one-half per 
cent of cases of chronic catarrhal otitis media. Beverley Robinson, 
without giving definite statistics, makes the statement that aural 
complications are met with in atrophic rhinitis far more frequently 
than in hypertrophic. Buck, Roosa, and Mittendorf apparently 
make no distinction between the two forms of rhinitis, as causing 
ear complications. 

I have always regarded hypertrophic rhinitis as a very active 
cause of middle-ear troubles, in the manner already described in the 
chapter on that disease. Certainly in a given number of cases of 
grave impairment of hearing, the number due to the hypertrophic 
disease outnumbers those due to the atrophic disease in far greater 
proportion than the comparative frequency of the two affections. 
Furthermore, when we consider the success of our treatment of hy- 
pertrophic rhinitis, and our failure to do more than relieve the 
atrophic form, it would seem that my own observation as regards the 
relative frequency of these causes of ear disease is the correct one. 
The manner in which hypertrophic rhinitis acts to produce middle- 
ear disease, has already been described, and would seem clear and 
direct. On the other hand, the action of the atrophic form of the 
disease in producing ear complications does not seem so clear. I 
am disposed to think that the ear is quite as dependent upon healthy 
nasal passages as the bronchial tubes. In other words, the air which 
reaches the orifice of the Eustachian tubes should reach that region 
through the nose, and be at normal atmospheric pressure, of the tern- 



100 DISEASES OF THE NASAL PASSAGES. 

perature of the body, and in a state of saturation. Any departure 
from these conditions involves danger both to the ear and to the 
bronchial tubes. 

Diagnosis. — An examination anteriorly will reveal on first inspec- 
tion each cavity more or less filled with greenish-yellow crusts, lying 
upon the faces of the lower and middle turbinated bones, and bridg- 
ing across the intervening space to the septum. These crusts present 
an appearance which is absolutely characteristic of atrophic rhinitis, 
in their peculiar greenish-gray tint, thus differing essentially from 
the crusts found in ulceration and necrosis, which are mingled with 
blood, unhealthy pus, and necrotic tissue. They are usually found 
in the front portion of the nasal cavity, while an examination by pos- 
terior rhinoscopy will show the turbinated bones comparatively clean. 
If now the crusts be removed by the forceps or probe from the sur- 
faces of the turbinated bones, there will be found underlying them, 
and apparently oozing from the fissure between the lower and middle 
turbinated bones, and also from beneath the upper, healthy -looking 
whitish-yellow muco-pus. After thoroughly cleansing the cavity by 
means of the syringe or coarse spray, if the disease is in its earlier 
stages, we find the mucous membrane over the lower and middle tur- 
binated bones presenting a fairly healthy aspect, normal in color and 
contour. Thus far, the only evidence of the disease which we have 
met with, is in the characteristic crusts. In the later stages of the 
disease, however, we find on thoroughly cleansing the cavity, the 
membrane covering the lower and middle turbinated bones present- 
ing a somewhat bloodless appearance, and adhering closely to the 
turbinated bones beneath, and having the appearance of a thin and 
somewhat attenuated membrane, while the bones themselves, accord- 
ing to the stage of the disease, present a shrunken and atrophied ap- 
pearance, leaving a noticeably large roomy cavity, through which the 
wall of the pharynx may easily be recognized. In advanced cases the 
turbinated bones may even be difficult to find, presenting simply 
small, cord-like protuberances along the outer wall of the cavity. 

An inspection of the pharynx, both in the early and late stages 
of the disease, will show a dry, glazed, parchment-like condition in 
its lower portion, while in the vault will be noticed a plug of thick 
mucus, adherent to the pharyngeal roof and more or less discolored 
by the dust of the inspired air which has not been arrested in its 
passage through the nose. The larynx and trachea present a fairly 
normal appearance, unless there are visible flakes of inspissated mu- 
cus, or in rarer cases dry incrustations. The membrane lining these 
cavities may be somewhat congested, presenting evidences of a condi- 
tion of chronic hyperemia, but rarely of a catarrhal inflammation. 



ATROPHIC RHINITIS. 101 

Prognosis. — When we consider the essential character of the dis- 
ease, we can easily appreciate that we have to deal with an exceed- 
ingly obstinate affection and one which in most cases will resist all 
treatment. The question presents, Can we cure it? Frankel, of 
Berlin, very frankly says: "A cured ozaena is unknown to me," re- 
ferring to atrophic catarrh. In the early stage of the disease, before 
the fetid symptoms have set in, I have seen cases recover. In the 
advanced stages characterized by fetor, and in which the turbinated 
bones have almost entirely disappeared, I have not seen a case cured, 
if, by a cure, is meant a condition secured in which there remains no 
necessity for any measure of local treatment. All cases can, I be- 
lieve, by thorough and painstaking treatment, be brought to that 
point when, by the use of very simple means, the ground that has 
been gained can be secured, and the patient be kept entirely free from 
any annoying symptoms, so long as he continues to make use of some 
simple cleansing lotion applied three or four times daily, but we are 
never justified in holding out to our patient any hope of a genuinely 
radical cure. 

Treatment. — The first indication in the treatment of the disease 
is, of course, the thorough cleansing of the cavities, by the removal 
of all the incrustations. In the accomplishment of this end, there is 
no special virtue in any remedy, or local agent. The literature of the 
subject embraces a formidable array of drugs, among which are 
prominent carbolic acid, salicylic acid, boric acid, permanganate 
of potassium, phosphate of sodium, bicarbonate of sodium, thymol, 
borax, etc. The essential requisites of a good cleansing lotion are 
secured by the use of any solution which is alkaline and is disinfec- 
tant. The fluid should be alkaline for its solvent action upon mucus. 
It should be disinfectant, in order to neutralize the results of the 
process of decomposition which is going on in the retained secre- 
tions. Any fluid, then, possessing these qualities, is an efficient 
cleansing solution. The formula I generally prefer is the Dobell's 
solution, as follows: 

1$ Acidi carbolici., . gr. xij. 

Sodii bicarb., 3 ss. 

Glycerini, I ij. 

Sodii biborat. , . 3 i. 

Aquae, ad Oi. 

M. 

Of quite as much importance is the method by which the cleans- 
ing is accomplished. The most efficient douche we possess is the 
ordinary post-nasal syringe. By means of this instrument a stream 
can be driven with great force through the cavities. In ordinary 



102 DISEASES OF THE NASAL PASSAGES. 

cases, tliis is sufficient to thoroughly detach all the crusts, and cleanse 
the parts. In advanced cases, however, it will be necessary to use a 
probe wrapped with a pledget of cotton. This can be passed through 
the nostril and along the turbinated bones, thereby separating the 
crusts, after which they can be easily washed out with the syringe. 
Occasionally it will be necessary to throw a stream through the nos- 
tril by means of an ordinary ear-syringe. The essential point is to 
remove all secretions from the nose, and the success of the manipula- 
tion can be determined only by repeated inspections by means of a 
good illumination, and with the anterior nasal speculum in place. 
After the parts are thoroughly cleansed, the next step consists in the 
application of a stimulant agent. If the disease is essentially an 
atrophic process, and the fetor is due to a process entirely outside of 
the membrane, then the rational treatment, and the one directly cura- 
tive of the disease in the membrane proper, is to stimulate the parts 
to a better performance of their normal function, viz. , the secretion 
of mucus. 

Gottstein advocates the use of the cotton tampon for the promo- 
tion of secretion and the correction of fetor, in atrophic rhinitis. 
Beverley Robinson indorses their utility, while Woakes makes use 
only of Gottstein 's tampons for the purpose of applying powders to 
the diseased membrane, thus securing the local action of his medica- 
ment together with such benefit as may result from the plugging 
process. Both Sajous and Mackenzie advise the use of the galvano- 
cautery at white heat, as first recommended by Frankel. Lennox 
Browne considers this decidedly the best treatment, and follows the 
application of the cautery with insufflations of iodoform or iodol, 
claiming to relieve thereby both the ozsena and the aural symptoms. 
Woakes recommends the application of iodoform in ether, in the 
form of spray. Cohen recommends the vapor of ammonium chloride, 
administered by means of Lewin's apparatus. 

As regards the use of the galvano-cautery, it seems to me this 
measure should be resorted to with the greatest caution, as it is an 
agent capable of doing much mischief. The essential feature of the 
disease is loss of tissue, a condition which might be enhanced by so 
powerful a destructive agent. As a stimulating measure, however, I 
can see how, with care, it might be attended with good results, 
especially in the earlier stage of the disease. Iodol and iodoform I 
have never regarded as agents of much power, other than as disinfec- 
tants, although Seifert recommends the insufflation of iodol, after the 
cavity has been tamponed for one or two hours according to Gottstein' s 
method. 

Following a previous suggestion of Shurley, as to the treatment 



ATROPHIC RHINITIS. 103 

of pharyngitis sicca by means of the galvanic current, Bryson 
Delavan, of New York, recommends this treatment for a similar 
nasal condition. His method is as follows : The positive electrode is 
to be placed on the nape of the neck, while the negative is wrapped 
in absorbent cotton and applied directly to the nasal mucous mem- 
brane. The strength of the current is from four to seven milliam- 
peres, the duration of the application being from seven to fifteen 
minutes, or until a moderate watery secretion is induced. Delavan 
secures excellent results from this plan of treatment, which seems 
exceedingly rational and well worth a trial. 

The primary cleansing of the parts must be done at first by the 
physician, in the manner already suggested. At the commencement 
of treatment it will be necessary to see the patient daily, or perhaps 
three times each week. After the disease has been brought somewhat 
under control, the intervals of attendance at the office may be 
lengthened as may seem best. At the same time the patient should 
be directed to provide himself with an atomizer, preferably the 
Burgess, in which there may be used any simple alkaline or disin- 
fectant lotion, such as the Dobell's solution already given. This is 
to be thoroughly applied to each passage fixe or six times daily if 
necessary. The patient, being instructed as to the character of his 
disease and the indications for treatment, will easily appreciate the 
object of the spray, viz., to prevent crust formation, and will make 
the applications as they may be needed. 

An exceedingly convenient cleansing lotion, and one which I 
frequently use, has been suggested by Seiler, composed of several of 
the salts of sodium in combination with thymol, eucalyptol, menthol, 
etc. It is made into the form of a tablet, and sold in the drug stores 
as Seiler' s Antiseptic Tablets. One tablet dissolved in two ounces 
of water forms a solution of the proper strength. 

In addition to the frequent use of the spray, the patient should 
be directed to use once each day, by means of the nasal douche, 
from one to two quarts of hot water, in each quart of which a 
tablespoonful of salt has been dissolved. This should be used as hot 
as can be tolerated. The beneficial effect of this is especially notice- 
able at the commencement of the treatment, in altering the character 
of the discharge, rendering it less purulent, and thus controlling crust 
formation. It acts probably both in controlling cell proliferation 
and in giving tone to the walls of the venous sinuses, as well as a 
cleansing wash. 

In addition to the above I have occasionally found some benefit 
from the use of local applications, in the form of snuff, of certain 
drugs whose action is to stimulate the membrane to a freer secretion. 



104 DISEASES OF THE NASAL PASSAGES. 

As before stated, the general health of patients suffering from 
atrophic rhinitis is not usually affected, and hence there are no 
indications for internal medication. These patients, however, as well 
as all who suffer from catarrhal disorders, are peculiarly susceptible 
to changes in the weather, etc., and hence their habits of life, general 
hygienic surroundings, clothing, bathing, etc., should receive full 
attention at the hands of the physician. 



CHAPTER XII. 
CROUPOUS OR FIBRINOUS RHINITIS. 

Ckoupous rhinitis is an acute inflammation of the mucous mem- 
brane lining the nasal passages. It occurs in both children and adults, 
although in children it is more protracted and its symptoms more 
aggravated. It is characterized by a deposit of fibrinous exudation, 
which presents the anatomical features of a croupous membrane, viz., 
one which is superimposed upon the epithelial layer and does not 
involve the deeper tissues. It has already been stated, in the chapter 
on mucous membranes, that a fibrinous exudation is mainly to be re- 
garded as a local manifestation of a general blood condition, a local 
exudation involving no serious danger to life, except when it involves 
the lar} r nx. 

This disease is of frequent occurrence, and yet is mentioned but 
rarely in current literature. Friinkel refers somewhat casually to it, 
as a complication of diphtheritic disease of the nose, while Schuller 
gives a somewhat more accurate description of it, but still appends 
the name diphtheritic. Cohen refers to a fibrinous exudation as a 
somewhat rare occurrence in acute coryza. He undoubtedly recog- 
nized the disease as distinct from diphtheria, but, with this exception, 
we find that most writers entertain exceedingly vague ideas as to the 
distinctive character of the two affections. 

Etiology. — Strazza, in a report of two cases, says he discovered 
the Klebs-Loeffler bacillus in the membrane of one ; in the other he 
found a streptococcus which resembled neither the bacillus of ery- 
sipelas nor the pyogenes. Concetti reports five cases of pseu do- 
membranous rhinitis; from two were obtained the Klebs-Loeffler 
bacillus ; in two others there was a history of direct infection from 
one to the other, with paralysis in one of them ; in the fifth there 
was a secondary appearance in the larynx. Baginsky, Park, Abel, 
and Birkett report cases in which they found the true diphtheritic 
bacillus. 

The disease undoubtedly is frequently caused by or follows opera- 
tions in the nose, not only after the galvano-cautery, but also any 
operation which involves a section of the membrane. A croupous 



106 DISEASES OF THE NASAL PASSAGES. 

membrane forms on the cut surface without manifesting any tendency 
to extend, and while the local symptoms are not so marked, the febrile 
symptoms are often quite as acute as those in an idiopathic case of the 
disease. 

Pathology. — The essential pathological lesions observed in the 
mucous membrane proper, are those of an ordinary acute rhinitis. 
On the surface of the membrane, and somewhat closely adherent to it, 
is a false membrane, which presents under the microscope the ordi- 
nary appearances of a croupous membrane. Exudation occurs on the 
faces of the lower and middle turbinated bones, and, in aggravated 
cases, on the septum in the anterior portion of the nares. I have 
never noticed any tendency to extension to the accessory sinuses, 
although their orifices are closed by the swollen nasal membrane and 
distressing symptoms referable to those cavities may occur thereby. 

Symptomatology. — The disease is generally ushered in by chilly 
sensations, and more rarely by a well-marked chill. This is followed 
by general febrile condition, by headache, pains in the bones, and 
loss of appetite. Coincident with these, symptoms of acute rhinitis 
set in, characterized by swelling of the nasal membrane, stenosis, 
watery discharge, and sneezing. The dry stage is omitted, and 
there immediately sets in a sero-mucous discharge from the nose, 
which soon becomes somewhat purulent in character. The amount of 
the discharge is rather excessive throughout the whole course of the 
disease, but never assumes a fetid character or gives rise to any 
offensive odor. 

At the onset of the disease, the thermometer will often show a 
temperature of 101° to 103° F., which, lasting one or two days, subsides 
somewhat, and the further progress of the attack is accompanied by a 
temperature of 100° to 101° F. ; although in adults the temperature may 
become normal after the second or third day. The local symptoms 
referable to the nose are oftentimes of a very distressing character. 
There is usually complete stenosis, with loss of the sense of smell, 
together with frontal headache, and oftentimes severe neuralgic pain 
along the course of the nasal nerve. The disease usually extends to 
the glands in the vault of the pharynx, and occasionally to the faucial 
tonsil". In these regions, however, we usually find a simple follicular 
tonsillitis, the croupous exudation confining itself to the crypts of the 
follicles, although Moldenhauer has seen a true fibrinous membrane 
on the faucial tonsil. 

Diagnosis. — If care be exercised in the examination and the 
secretions removed from the passages, the characteristic pearly white 
membrane will be seen covering the nasal lining and extending down 
very closely to the muco-cutaneous junction. In some cases, the 



CROUPOUS OR FIBRINOUS RHINITIS. 107 

membrane does not extend near to the margin of the nostril, and the 
nasal cavity is obscured by the swelling of the turbinated tissues, 
and the excessive amount of secretion; and, furthermore, cocaine is 
of little avail in shrinking up the membrane and opening the cavity 
to inspection. In such cases, the diagnosis will be aided by gently 
wiping out the cavity with a pledget of cotton on the probe, and 
endeavoring to detach a portion of the false membrane, whose 
presence should be suspected in every case of apparent acute rhinitis 
in which the constitutional symptoms seem excessive and the local 
symptoms of so aggravated a character. 

In adults, the false membrane is small, thin, and easily recognized 
as a croupous exudation, and furthermore is not attended with exces- 
sive muco-purulent secretion. In children, however, the exudate 
often forms a soft, thick, almost granular mass, very friable, which 
in some cases can almost be wiped from the mucous membrane in 
small fragments. A bacteriological examination of the membrane is 
always imperative. 

Prognosis. — The prognosis is favorable. The disease runs its 
course in adults in from eight to fourteen days, while in children it 
usually lasts from three to five weeks. 

General Treatment.— Abbot has shown that the treatment 
appropriate to diphtheritic cases is most often used with benefit in 
these cases. The patient should be isolated at once. Tincture of 
iron should be administered in full doses, as soon as the disease 
is recognized. 

Some preparation of quinine or cinchona should be given with 
iron, for its general tonic effect. In young children, in whom the 
pseudo-membranous formation assumes a rapid and efflorescent type, 
I believe the efficacy of mercurial treatment should be thoroughly 
tested in the early stage of the attack. Preference should be given to 
the use of the mild chloride, which may be administered in full doses, 
frequently repeated. 

If, at the end of the second day, decided amelioration of the 
local symptoms is not noticed, the iron treatment had best be substi- 
tuted. If fever is present it should be managed on the same general 
principles which govern our administration of remedies in other 
febrile conditions in chidhood. The same, of course, may be said in 
regard to the necessity of laxatives, etc. 

Local Treatment. — Our first effort should be directed toward the 
removal of the membrane, care being taken not to injure the soft parts 
beneath, or better still, if free access can be obtained to the pseudo- 
membrane, it should be destroyed in situ, its capacity for mischief 
being ablated and the inert film left in place, to prevent a new 



108 DISEASES OF THE NASAL PASSAGES. 

growth. This, I think, can best be done by one of the iron prepa- 
rations. The use of cleansing washes by means of an atomizer is 
grateful to the patient, if feasible, but in young children the stenosis 
is so complete as to render their availability somewhat limited. 

Moldenhauer recommends the use of warm inhalations, while 
Hartmann and Bresgen both recomend the use of iodoform after the 
removal of the membrane, either as an insufflation or in suspension 
in glycerin. Cocaine, as before stated, has but a limited action in 
controlling the stenosis. If the part can be sufficiently cleansed, 
however, to admit of the application of cocaine, a four-per-cent solu- 
tion should always be resorted to, and frequently repeated, both as 
controlling the blood supply and relieving nasal stenosis. 



CHAPTER XIII. 

NASAL REFLEXES. 

The subject of nasal reflexes is one which possesses great interest, 
not only because of its curious symptoms, but also from the broad 
field it now embraces, the result of increased knowledge of intra- 
nasal disease. To Marshall Hall the credit is due of first making 
clear the phenomena of reflex actions, though it seems that Johann 
Mueller was pursuing a similar line of investigation, the results of 
which were published the same year. Many of the earlier physiol- 
ogists however, had already recorded these phenomena, notably 
Whj^tt, Procheska, and Cullen, who recognized the reflex character 
of sneezing, coughing, vomiting, etc. 

This reflex tendency is very active in the respiratory apparatus, 
especially in the nose. Thus Brown-Sequard (cited by Euault) 
observed that by plunging the nose into cold water respiration and 
cardiac action would be stopped, while Kratschemer aud Francois- 
Franck, as cited by the same author, showed that thermic, mechanical, 
or chemical irritation of the nasal fossae can reflexly produce a draw- 
ing up of the nares, arrest of respiration in expiration, momentary 
arrest of the heart, and slackening of the pulse. The first writer to 
call attention to the nasal reflex was Voltoliui, who reported a case of 
spasmodic asthma, dependent on the existence of nasal polypi, which 
was cured by the removal of the growths. This observation has been 
verified by so large a number of writers that it seems to me the 
connection between the two diseases cannot well be questioned, 
though Lennox Browne and Boecker state that, in many instances, 
the asthmatic symptom persists, even after the removal of the polypi. 
This question, however, is more fully discussed in the chapter on 
asthma. 

The possibility of other reflexes due to intranasal disease was not 
recognized until Seiler published two cases of reflex cough, due to a 
hypertrophic rhinitis; followed by Hack, who observed a case of 
spasmodic cough due to a fibrous polypus. A similar observation 
was made by John Mackenzie. 



110 DISEASES OF THE NASAL PASSAGES. 

Some years previously, however, Bichet had reported a case of 
convulsive tic douloureux, which was cured by the removal of an 
enchondroma of the nasal septum. 

Interest in nasal reflexes was first excited when Hack reported 
a large number of nasal reflexes; gastralgia and dyspepsias; cardiac 
palpitation ; tumefaction and redness, either temporary or permanent, 
of the skin of the nose ; transitory and circumscribed cedemas ; sali- 
vation ; neuralgia of the first two branches of the trigeminus ; cephal- 
algia; migraine; scotoma; ciliary neuralgia; photophobia; vertigo; 
agoraphobia ; and exophthalmic goitre. 

These affections Hack found were due to various forms of intra- 
nasal diseases, although the large majority was dependent upon 
hypertrophy or chronic hyperemia of the nasal membrane. Hack 
thinks that simple hyperemia without hypertrophy is more fre- 
quently a source of nasal reflex than a true hypertrophy with tissue 
change, and that sneezing, watery discharge with stenosis alternating 
from one side to the other constitute conditions which indicate, almost 
pathognomonically, that the turbinated bodies are the source of reflex 
phenomena. This is undoubtedly true, for these symptoms indicate 
not an ordinary catarrhal inflammation, but a vasomotor paresis of 
the blood-vessels of the nasal mucous membrane, the essential condi- 
tion which exists in hay fever. This disease is not met with in highly 
neurotic individuals, and the neurotic habit, I take it, is the most 
active predisposing cause of a nasal reflex. 

An interesting symptom has been observed by Max Schaffer, of 
Bremen, who reports a case of complete loss of voice, with no observ- 
able lesion of the larynx, in a case of hypertrophic rhinitis. Local 
faradization proving useless, the cure was effected by treatment 
directed to the nasal hypertrophy. Elsberg reports a case of chorea, 
occurring as a reflex due to hypertrophic rhinitis. Similar obser- 
vations have been made by J. L. Sallinger and the author. Cases 
of epilepsy, due to intranasal disease, have been reported by Sallin- 
ger, Fincke, and myself, while a case of psychical epilepsy has been 
reported by T. A. McBride. Ziem reports, among the reflex symp- 
toms, a case of nocturnal enuresis. Dr. North, in adding neuras- 
thenia to the list of nasal reflexes, goes so far as to state that he has 
yet to see a case of neurasthenia in which there is not some catar- 
rhal trouble. 

Salivation would seem a rather curious reflex disturbance, as a 
result of intranasal disease, and yet two such cases have come under 
my own observation, in elderly people. In both these cases the 
result of treatment was quite successful. A similar case has been 
reported by E. Frankel, as cited by Kuault. 



NASAL REFLEXES. Ill 

The question of ocular disturbances dej)endent on intranasal dis- 
ease seems to have excited the attention of American observers more 
notably than of foreign, although Hack mentions weak, watery eyes in 
his list of affections. In an able paper by Dr. Gruening, a number 
of cases of photophobia with mild conjunctivitis were reported as 
cured by treatment for intranasal disease. Similar observations have 
been made by Beverley Robinson. Cheatham, also, holds that many 
cases of asthenopia are due to intranasal disease. B. Bettman, of Chi- 
cago, reports six cases of epiphora, conjunctivitis, photophobia, and 
pain above the eyes, due to nasal disease, which were cured by 
galvano-caustic applications to the inferior turbinated bones. Len- 
nox Browne reports a case of glaucoma not benefited by iridectomy 
but cured by the eradication of a nasal polyp. 

If we attempt to explain these various reflexes we find ourselves 
compelled to adopt rather vague and indefinite theories, which are 
quite as obscure as the reflexes themselves. Mackenzie claims to 
have discovered certain sensitive areas in the nose, which are peculiarly 
connected with the evolution of the reflex act. These areas embrace 
simply that portion of the nasal mucous membrane wherein we have 
the turbinated bodies, which, owing to their intense and constant 
activity as an important part of the respiratory apparatus, must 
necessarily be exquisitely sensitive, far more so than other portions 
of the nasal chambers. 

That the condition in the nose which more frequently causes reflex 
action is hyperemia rather than hypertrophy, as stated by Hack, 
I think is fully borne out by clinical observation. Moreover, this is 
easily explained by the fact that hyperemia generally occurs in 
patients of a decidedly neurotic temperament. That the neurotic 
temperament is a prominent predisposing cause of a nasal reflex, I 
think none will question. John Mackenzie, also, recognized that 
" where complete atrophy of the turbinated structures existed, as for 
example in ozaana, reflex action was not present, nor could it be in- 
duced by artificial stimulation." That reflexes, however, never occur 
in connection with atrophic rhinitis, cannot be asserted when we con- 
sider that such careful observers as B. Frankel and Schmaltz have 
reported cases of facial neuralgia and vertigo occurring as nasal 
reflexes in atrophic rhinitis. Finne also cites a case of neuralgia of 
the fifth nerve of three months' duration, in an anaamic woman of fifty, 
which was dependent on atrophic rhinitis. The reflex in these cases 
is most probably due to impaired general nutrition. Furthermore, 
the cause of these neuralgias is the same as of the frontal headache 
which occurs in acute coryza arising either from occlusion of the orifice 
or from congestion of the lining membrane of some of the accessory 



112 DISEASES OF THE NASAL PASSAGES. 

sinuses, producing nerve pressure. If we glance now at the various 
diseases which occur, we find that they divide themselves into neu- 
ralgias, spasmodic or paralytic nervous affections, and ocular symp- 
toms ; the neuralgias, embracing migraine and cephalalgia, occur only 
in patients suffering from impaired general nutrition. Any patient, 
I take it, suffering from an obstructive lesion in the upper air passages 
feels, to a certain extent, the systemic effect of the resultant impairment 
of the process of oxidization. 

In the large majority of cases, spasm of the glottis is a direct 
symptom. Where it occurs as a reflex, the method of development 
probably is much the same as in an asthmatic attack. Owing to the 
iDtimate connection between the two regions, as parts of the respira- 
tory apparatus, any vasomotor disturbance in the nasal mucous 
membrane is liable to give rise to disturbances in other portions of 
the passages. In the same manner we may explain the occurrence 
of spasmodic contraction of the faucial or palatal muscles which has 
been recorded by Seifert, who reports a case of chronic contraction 
of the muscles of the face, soft palate, and Eustachian tube, with ob- 
jective and subjective gurgling sounds in the ear, due to a chronic 
rhinitis, although local treatment failed to afford any relief; while 
Michel has observed "chronic spasm of the Eustachian tube, with 
objective and subjective gurgling sounds in the ear," in a lady of forty 
years of age, relieved by removal of polypi with the cold snare. 

Functional aphonia is always, I think, a pseudo-paresis of the 
adductor muscles of the larynx, and occurs, as a rule, in hysterical 
females. I have seen cases such as Schaffer reports, in which the 
loss of voice was apparently a nasal reflex, and, furthermore, in which 
apparently the success of nasal treatment justified this view, and yet 
the aphonia sooner or later recurred, as is the usual rule in hysterical 
affections of the larynx. 

Chorea is one of the diseases which, when dependent upon intra- 
nasal disease, gives most satisfactory results from treatment. I have 
seen a number of such cases in which the choreic movements disap- 
peared completely and permanently with the cure of the nasal disorder. 
Dr. Jacobi has also found chorea associated with chronic rhinitis, 
enlarged tonsils, and other obstructive lesions of the air passages. 

Sallinger and Fincke both report cases of epilepsy cured by 
treating concurrent intranasal disease, while B. W. Richardson re- 
ports a case of a lady thirty -four years old, cured of epilepsy by the 
removal of a post-nasal fibroma. My experience has been less fortu- 
nate, for, although in three cases which have been under my treat- 
ment great improvement, and in one case an apparent cure, followed 
the removal of obstructive nasal lesions, in all cases the disease re- 



NASAL REFLEXES. 113 

turned. In these cases the epileptic habit probably had become so 
far fixed that the seizures were not controlled by removing the con- 
tributing cause. Id the same category, probably, might be included 
vertigo, which is rather a frequent reflex nasal symptom. 

Ocular reflexes present many points of clinical interest, and yet 
when we attempt to state the direct connection that exists we find 
ourselves again treading on purely theoretical grounds. Gruening 
was probably the first to call prominent attention to these reflexes, 
all of which were relieved by treating a pathological condition of the 
nasal membrane. 

Regarding the success of treatment in these cases, it is safe to say 
that in none of the reflexes are the results more thoroughly satisfac- 
tory than in morbid lesions of the eye dependent upon a diseased 
nasal mucous membrane. 

While there are no diagnostic signs which enable us to recognize 
reflex disturbances as due to intranasal disease, it should be borne in 
mind that those cases in which such phenomena occur, as a rule, 
show evidence of a decided neurotic temperament. If on examina- 
tion of the nasal cavity we find the mucous membrane swollen and at 
the same time presenting the watery appearance, while it is not itself 
notably reddened, it should immediately suggest to us a paretic con- 
dition of the vasomotor control. If, now, a four-per-cent solution of 
cocaine be applied by means of an atomizer, and the membrane, 
after contraction, is seen to cling closely to the turbinated bones 
beneath, showing no evidence of true hypertrophy, we have further 
indication of a neurotic condition. 

Hack has made much of his cocaine test for the existence of a 
reflex, making use of it to produce anesthesia, which, he says, when 
thoroughly established oftentimes will abolish the reflex phenomena 
demonstrated by the probe before the membrane was anesthetized. 
This would apply to reflex cough, laryngeal or faucial spasm, and 
possibly certain cases of neuralgia. Headache, if it is dependent 
upon nasal reflex, readily yields to the local application of cocaine 
in a very few minutes, and then, of course, the diagnosis is im- 
mediately established. This, however, I think applies only to the 
congestive headaches, the result being due to the contractile proper- 
ties of cocaine rather than to the anaesthesia. In ocular and other 
obscure reflexes we have no method of making a diagnosis other than 
by observing the success of local treatment. 

Nasal polypi and deformities of the nasal septum are not infre- 
quent conditions which give rise to reflex phenomena. I do not 
think, however, in either of these cases that it is the original lesion 
which causes the reflex, but rather a paretic condition of the mem- 



114 DISEASES OF THE NASAL PASSAGES. 

brane to which it gives rise. In nasal polypus it is generally 
stated that a watery secretion from the nose is due to the hygro- 
scopic character of the growth, by which it absorbs and discharges 
moisture according to the state of the weather. Personally, I am dis- 
posed to think that the source of the serous exudation is in the ve- 
nous sinuses. In other words, we have a vasomotor paresis of the 
mucous membrane, a condition most frequently associated with the 
reflex phenomena due to the presence of the growths. The frequency 
with which polypus is attended with reflex neuroses, I think, is due 
to the fact that in the majority of cases it impinges upon and irritates 
the mucous membrane covering the middle turbinated bone, and this 
region is probably more frequently the source of reflex disturbances 
than the lower passage, on account of its more delicate sensibility. 

When, therefore, we find a nasal polypus giving rise to asthma, 
this is not due directly to the presence of the polypus, but to the 
morbid condition in the mucous membrane caused by the presence of 
the polypus. On the other hand, when a supra-orbital neuralgia or a 
simple headache occurs as a reflex symptom, I think we give a more 
rational explanation of the symptom in saying that it is due to pres- 
sure exercised on the peripheral nerves. When an examination fails 
to reveal any evidence of vasomotor disturbance in the nasal mucous 
membrane, we must attribute reflex disturbances to a simple hyper- 
trophic rhinitis. In rare cases adenoid growths in the vault of the 
pharynx become a source of reflex symptoms. 

In the local treatment of these conditions, I am convinced that 
successful results are due primarily to the removal of the local intra- 
nasal disease. 

The neurotic habit is a prominent factor in the production of these 
disturbances in man}- cases, and always requires attention. In these 
cases no measure is of greater importance than the use of cold water. 
If well tolerated, a cold sponge down the spine once daily, or better 
still a shower or douche, will aid us very materially. In addition to 
this there are two drugs which I regard as of special value, viz., zinc 
and belladonna. These may be given either singly, or, as I prefer 
it, in the following pill : 

1$ Ext. belladonnas, grs. v. 

Zinci oxidi, grs. x. 

M. ft. mass, in pil. numero xx. div. S. One pill to be taken three times daily 
before eating. 

Arsenic is a remedy which possesses a certain efficacy. Iron, 
strychnine, and general tonics, which we are so often led to prescribe, 
I think possess but limited value in controlling the neurotic habit, 
and hence should not be administered unless specially indicated by 
other general conditions. 






CHAPTER XIV. 

HAY FEVER, OR VASOMOTOR RHINITIS. 

John Bostock first attracted prominent attention to this affection, 
although Beschorner has shown that it was recognized by writers in 
the sixteenth century. Since then various authorities have conducted 
experiments with a view to discovering the nature of the disease. In 
1882 Daly suggested a diseased condition of the nasal cavities as 
being an important factor in all cases of hay fever. AVhen this dis- 
ease was first recognized, it was thought to be due to the emanations 
of dry hay, and hence the term hay fever as applying to the form of 
the disease usually met with in the later months of the summer. Sub- 
sequent investigation revealed that a form of the disease occurred in 
the early summer months, to which the name rose cold was given. 
Still later we find appearing in the literature of the subject such 
names as summer catarrh, pruritic catarrh, pollen catarrh, peach 
cold, etc. The disease is essentially the same, in whatever season it 
may appear, and hence we use the term hay fever as a generic ex- 
pression and as embracing all forms of the affection. 

Definition. — We may define hay fever, then, as a disease charac- 
terized by the annual recurrence, at a certain season of the year, usu- 
ally the same period in each individual case, of an attack of a more 
or less aggravated form of influenza, the prominent symptom of 
which is an intensely swollen condition of the mucous membrane 
lining the nasal cavities, attended with sneezing and profuse watery 
discharge, these symptoms being due to the direct impact upon the 
mucous membrane of the nasal passages of the pollen of certain 
flowering plants, present in the atmosphere. 

History. — In 1886 the author published a paper in which it was 
argued that the prominent predisposing cause of all cases of hay fever 
was an obstructive lesion in the nose, giving rise to a vascular dilata- 
tion, caused by the rarefaction of air in the nasal chambers behind the 
point of obstruction, and further that three conditions were essential 
for the production of the disease : (1) an obstructive lesion in the 
nose, (2) a neurotic habit, and (3) the impact of pollen upon the 



116 DISEASES OF THE NASAL PASSAGES. 

nasal mucous membrane. At the same time it was argued that hay 
fever and asthma were identical, in that one disease was a vasomotor 
rhinitis while the other was a vasomotor bronchitis. In 1887 Sir 
Andrew Clark, in a paper on the subject, assigned three causes for 
the disease, viz. : a neurotic habit, an intranasal pathological condi- 
tion, and an external exciting cause. The later literature indorses 
these views, and we find few writers who do not accept what I think 
is to be regarded as the most important of these conclusions, viz., 
that which regards a morbid lesion of the nasal membrane as a 
prominent factor in causing the attacks. 

Etiology. — At the time of the publication of Bostock's second 
paper, the idea seems to have been prevalent that the emanations of 
dry hay had much to do in causing the attack, although Bostock 
hiroself regarded this as less active than heat and physical exertion. 
Phoebus thought that sunlight played an important part in the pro- 
duction of the disease, although he conceded a certain amount of 
activity to the emanations from flowers and grasses. I think a great 
mistake was made by the earlier investigators, in that, while search- 
ing successfully for the cause of an exacerbation of hay fever, they 
seemed to regard the pollen as a cause of the disease itself. Beard's 
brochure was a notable departure from the line of investigation hitherto 
pursued, in that the analysis of the large number of cases which he 
collated proved beyond question that the neurotic habit was present 
in all individuals subject to hay fever, and, still later, Daly's origi- 
nal suggestion of a local morbid condition of the nasal mucous mem- 
brane added a third factor to the causation of the disease. We thus 
find that there are three essential conditions necessary for the pro- 
duction of an exacerbation : 

1. The presence of pollen in the atmosphere; 

2. A neurotic habit; and 

3. A local morbid condition of the nasal mucous membrane. 

1. The Presence of Pollen in the Atmosphere. — The pollen theory 
of hay fever has probably received larger discussion than any other. 
That the presence of pollen in the atmosphere and its impact upon 
the mucous membrane of the upper air passages are the immediate 
cause of the exacerbation, I think cannot be questioned, in view of 
the exhaustive experiments of Blackley. 

The question arises, How does pollen act on the mucous mem- 
brane? This we cannot answer, other than to state that it pro- 
duces vascular dilatation when present in the atmosphere in certain 
quantities. Thus, Blackley has shown that the condition of the at- 
mosphere which will deposit twenty-seven grains of pollen on a disc 
one centimetre in diameter, in twenty-four hours, is unirritating, 



HAY FEVER, OR VASOMOTOR RHINITIS. 117 

but increase the strength of the atmospheric suspension of pollen 
until it will deposit two hundred and eighty grains, and we find it pro- 
ducing marked symptoms of irritation. In the same way, a solution 
of cocaine, one grain to the ounce of water, will have little or no effect 
locally applied to the mucous membrane ; increase the strength of the 
solution to twenty grains to the ounce of water, and apply it to the 
mucous membrane, and the result is marked contraction of the blood- 
vessels. In other words, pollen in the air produces vascular dilatation 
in certain individuals in exactly the same manner as a solution of co- 
caine produces vascular contraction. The most active pollens in the 
production of hay fever are those of the flowering grasses, such as 
the different varieties of meadow grass, sweet-scented vernal grass, 
meadow fox-tail, golden-rod, etc. 

2. The Neurotic Habit. — The neurotic habit, as demonstrated by 
Beard, is an essential element of causation in hay fever, and serves 
to explain why certain individuals are sensitive to the action of a 
pollen-laden atmosphere, while others are exempt. What the essential 
pathological lesion is, in what we call the neurotic element in hay 
fever, it is not easy to explain. "We know, however, that clinical 
investigation shows in a sufficiently large proportion of cases of hay 
fever the existence of a family history showing evidence of neurotic 
tendencies, such as fully to justify the conclusion that behind all 
cases of hay fever lies a neurotic habit as a powerful predisposing 
cause of the disease. 

3. A Local 31orbid Condition of the Nasal Mucous Membrane. — A 
local morbid condition of the nasal mucous membrane, as a predis- 
posing cause, is present in probably all cases of true hay fever. This 
lesion must necessarily be one of an obstructive character, and one 
attended with vascular dilatation. The primary lesion, probably in 
most cases, is the obstruction, as shown by Harrison Allen. 

In addition to the three elements of causation already described, 
I think we must recognize a psychical influence in many of these 
cases, as acting to produce the attacks, a peculiar mental anticipation, 
as it were, which only can explain the fact of the annual recurrence 
of the disease at fixed dates, some patients going so far as to notice 
that their disease recurs even at a certain hour of the day each year. 
We can explain the recurrence of attacks in certain cases on fixed 
dates each year only by the fact that the individual's mind is so far 
concentrated on the anticipation of his attack that when the day 
comes the hay fever symptoms set in. This psychical influence is 
well illustrated by the case of John Mackenzie in which an attack of 
rose cold was precipitated by means of an artificial rose. Mackenzie 
also reports a case in which an attack of hay fever was brought on by 



118 DISEASES OF THE NASAL PASSAGES. 

a patient's gazing upon a picture of a field of hay. The explanation 
of these cases, I take it, is much the same as that of those cases of 
intermittent fever in which the paroxysm is postponed by changing 
the position of the hands of the clock. 

The minute organisms which Helmholtz discovered in the mucous 
discharge from the nose have never been verified by other observers. 
It is altogether probable that what Helmholtz really saw were frag- 
ments of mycelium-like threads thrown out by the pollen cells under 
the influence of heat and moisture, and containing the minute fovilke 
of the pollen cell. The relief which Helmholtz obtained by the injec- 
tion of his quinine solution, therefore, must be attributed largely to 
psychical influence ; for, while immediately following the publication 
of Helmholtz' experience, the use of quinine solutions became ex- 
ceedingly popular, it has fallen into complete disuse at the present day. 

Age seems to exert a certain predisposing influence in the causation 
of the disease, in that the larger number of cases develop early in life. 
Thus, in a series of eighty cases observed by the writer, there 
occurred : 



Between the ages of 1 and 10, 
" " " 10 " 20, 
" " " 20 " 30, 
" " " 30 " 40, 
" " " 40 " 50, 

Over 50, .... 



Total, 



9 cases. 

27 " 
16 " 
21 M 



80 cases. 



We thus find the large proportion of cases occurring between the 
ages of ten and twenty, while the predisposition seems to disappear 
very largely at the age of forty, although, rather curiously, among my 
own cases, I have had under treatment a patient in whom the disease 
developed at the age of seventy -three. 

All writers coincide in the statement that the disease belongs 
essentially to the better-educated classes, and that it occurs very 
rarely among the laboring people. This we can easily understand, 
when we consider that the disease is essentially a neurosis, and that 
its development is favored by the surroundings and habits of life of the 
upper classes, while the contrary is true among the laboring people. 

That the large preponderance of cases occurs among males is also 
a fact noted by all observers. In the five hundred and six cases 
reported by Wyman, Beard, Phoebus, and myself, three hundred and 
forty-two were males and one hundred and sixty -four females. This 
observation would seem rather to conflict with the idea that hay-fever 
is essentially a neurosis, in that we ordinarily associate the delicate 



HAY FEVER, OR VASOMOTOR RHINITIS. 119 

female physique with a neurotic temperament. Trie true explanation 
of the preponderance of male cases of hay fever is in the fact that 
males are much more exposed to those conditions which favor the 
development of catarrhal disease. This iact, then, would seem to 
lend weight to the view already indorsed, that a catarrhal affection of 
the upper air passages is a powerful predisposing cause to the devel- 
opment of hay fever. 

The powerful influence of heredity is well illustrated by Wy man's 
statistics, who found that in one-fifth of all his cases more than one 
member of the same family was affected. The same is true of eighteen 
of my own eighty cases, while in thirty -nine cases there was either 
hay fever or asthma in the family. 

The impairment of the general health observed after a protracted 
convalescence from a continued fever would occasionally seem to act 
as a predisposing cause of hay fever. Thus, Sajous has observed 
cases coming on after an attack of typhoid fever, whooping cough, 
malaria, or chicken pox, an observation which fully coincides with 
my own clinical experience. 

Pathology. — The essential pathological changes which take place 
in the nasal mucous membrane, are not those which characterize an 
inflammatory process, and yet from the various names which have 
been proposed for the disease, such as Ehinitis vasomotoria (Hertzog), 
Coryza vasomotoria periodica (John Mackenzie), Ehinitis sympathet- 
ica, etc., the inference would naturally be drawn that the exacerbation 
is regarded as an inflammatory process. The appearances, however, 
of the membrane in the nose, as will be shown later, do not present 
the characteristic features of an inflammatory action. The pollen of 
flowering j>lants, as has already been noted, possesses the peculiar 
property of producing more or less comx)lete paralysis of the nerves 
which control the exosmotic function; in other words, the impact of 
pollen upon this membrane x>roduces a complete relaxation of the 
large veins which compose the turbinated bodies, under which they 
become dilated and their walls admit of free transudation of serum, 
the veins remaining in this state of dilatation so long as the pollen is 
present upon the surface of the membrane in sufficient amount, re- 
gaining, however, their normal calibre immediately upon the removal 
of the exciting cause. The capillary blood-vessels of the mucous 
membrane proper, as a rule, are not involved in the morbid changes 
which take place in the deep tissues. The pollen, moreover, acts only 
to dilate those blood-vessels which are involved in its respiratory proc- 
ess, namely the venous sinuses of the turbinated bodies, for we find 
that the blood-vessels of the mucous membrane proper are unaffected 
by its action , retaining their normal calibre. We thus find that the 



120 DISEASES GF THE NASAL PASSAGES. 

exacerbation is due entirely to peripheral causes. It might be charged 
that this view militates against the neurotic theory. The part which 
the general predisposing neurosis plays in the production of the dis- 
ease is that it gives rise to a weakness of the vasomotor control, 
which the sympathetic and trigeminus nerves exercise over the calibre 
of the venous sinuses, whereby they are rendered susceptible to the 
action of pollen. The question arises now, whether this vasomotor 
susceptibility can be accounted for in any other way than by conced- 
ing some pathological change in the ganglionic centres. This is a 
question which cannot easily be decided, and any discussion of it can 
be carried on only upon theoretical grounds. I see no reason, how- 
ever, why the condition may not exist without necessarily involving 
the nerve centres in pathological changes, although the theory of a 
central lesion is ably advocated by John Mackenzie, who designates 
it as a "disordered functional activity of the nerve centres," while 
Kinnear is more definite in his conclusions, finding two forms of the 
disease, which are due in one case to a hyperemia, and in the other 
to a condition of anaemia of the sympathetic ganglia. Hack, on the 
other hand, believes that the morbid lesion consists essentially in a 
hyper aesthetic condition of the olfactory and the fifth pair of nerves. 
The same view is also entertained by Robinson. 

Symptomatology. — The onset of the attack is marked by a sense 
of irritation referable to the upper regions of the nasal chambers, with 
a sense of fulness or tightness across the bridge of the nose, accom- 
panied with sneezing of more or less violent character. At the same 
time patients complain of a curious burning or itching sensation about 
the roof of the mouth, apparently referable to the upper surface of the 
soft palate. As the attack develops, the nasal membrane becomes 
swollen, and the passages thereby more or less completely occluded. 
At the same time the serous exudation sets in, pouring out on the 
surface of the membrane and escaping from the nostrils in, often- 
times, large quantities. So profuse is this discharge that patients 
oftentimes feel apparently the passage of the serum in its escape from 
the blood-vessels, in a sense of intense irritation or formication about 
the root of the nose. The escape of serum seems to increase the 
intense irritation in the passages, as shown by the increased violence 
of the sneezing, which often occurs in paroxysms of considerable 
duration. With the occurrence of the nasal symptoms, in many cases 
there is felt at the same time irritation of the mucous membrane of 
the eyes, and in rarer cases even of the mouth and ears. These 
symptoms are undoubtedly due to the pollen acting on these mem- 
branes in exactly the same manner that it acts upon the nasal passages, 
as was shown by Blackley. 



HAY FEVER, OR VASOMOTOR RHINITIS. 121 

The blood in the membrane shows a certain hydrostatic character- 
istic, in that it tends to collect in the most dependent portion. Thus, 
if the sufferer lies on the back, the fluids collect in the posterior 
extremities of the turbinated bodies in such a way as to completely 
occlude the nares, while lying on the side will often have the effect of 
securing patency of the uppermost nasal passage, while the fluid 
collects in the lower. These symptoms show a tendency to abatement 
during the night, which is probably due to the fact that the air of 
the sleeping-apartment is less laden with pollen than the atmosphere 
breathed during the day. The waking hours, however, constitute a 
period of almost unbroken discomfort and suffering. The onset of 
the attack in most cases is sudden and without warning, although 
occasionally it is preceded by a feeling of general malaise, with loss 
of appetite and mental depression, these premonitory symptoms 
persisting during the course of the exacerbation to a more or less 
well-marked degree. Aside from these symptoms, evidences of the 
effect of the disease on the general system are not present. 

After the disease has persisted for a varying period of time, usually 
about two to three weeks, in a certain number of cases an attack of 
asthma sets in. These asthmatic attacks rarely occur with the first at- 
tack of hay fever, but the repeated annual visitation seems to develop 
a tendency which results eventually in the development of the bron- 
chial disorder. 

The question arises, whether the asthma is due to the hay fever, 
or whether they both may not be due to the same cause. I have 
discussed elsewhere the connection between hay fever and asthma, 
taking the ground that they are essentially one and the same 
disease, regarding hay fever as a vasomotor paresis of the walls of 
the blood-vessels lining the nasal cavity, while asthma is a vaso- 
motor paresis of the blood-vessels of the mucous membrane lining 
the bronchial tubes. 

There is an intensely active and quick sympathy between the 
nasal mucous membrane and the bronchial mucous membrane, under 
which a diseased condition in the nasal cavity tends to develop a 
similar morbid condition in the bronchial mucous membrane. It is 
probable also that the pollen acts with a certain amount of potency 
on the bronchial membrane, in much the same manner as upon the 
nasal membrane. The reason why it does not act to produce an 
attack of asthma with the first onset of the hay fever probably lies 
in the fact that this susceptibility in the bronchial tubes occurs only 
after they have been subjected to the weakening influence of the nasal 
disorder for a certain period of time. As the patient goes through 
his attack year after vear, it is noticeable that the asthma occurs in 



122 DISEASES OF THE NASAL PASSAGES. 

many cases earlier each year, until finally the asthma sets in immedi- 
ately on the advent of the hay-fever season. Still another curious 
fact noticed in these cases is that not infrequently the bronchial 
asthma seems to take the place of the hay fever. A still further 
change I have seen in these cases, by which the disorder becomes a 
perennial asthma, or in other words asthmatic attacks occur at all 
seasons of the year without reference to pollen in the atmosphere. 

Why the hay fever should disappear and the asthma take its 
place it is not easy to explain, unless that the peripheral irritation 
has resulted in an intensely irritable condition of the ganglionic 
centres. The essentially neurotic character of the disease is still 
further shown by the fact that in a certain number of cases the 
attack is preceded by a cutaneous eruption, usually of a lymphatic 
character, although Laflaive has met with cases of urticaria and even 
eczema. 

Course and Duration. — In a very large majority of cases of hay 
fever, the annual attack commences in the latter part of August and 
lasts until frost sets in. The usual date assigned is the 29th of 
August. Many patients assert that their attack recurs each year on 
exactly the same date, and even at the same time of day, although in 
most cases the date varies, it may be, several days. As before stated, 
I believe that in those cases in which the date and hour of the attack 
are absolutely unvarying, it is due to a peculiar state of mental anti- 
cipation which precipitates the attack. I know of no reason why so 
large a proportion of individuals are attacked in August. These 
cases are usually designated as autumnal catarrh. The next in 
frequency to this variety is that which occurs in June, and which is 
commonly spoken of as rose cold, from the fact that these patients 
are susceptible to the action of the pollen of the different varieties of 
roses which flourish at this season of the year. Most writers have 
regarded all cases as being of these two varieties.- Beard lays 
special emphasis on the fact that he had demonstrated a third variety 
as occurring in September. As before stated, however, this classifi- 
cation I think only serves to add confusion to the subject, as the 
disease is essentially the same at whatever season it occurs, and, 
moreover, in not a few instances we find that patients subject to the 
so-called rose cold are subsequently attacked in August with what is 
called autumnal catarrh. Still further, an analysis of cases will show 
that the attack may come on at any time from the first of May to the 
last of September. This Beard found in his one hundred and ninety- 
eight cases, the greatest number occurring between the 10th and 20th 
of August. 

These figures apply only to the onset of the attack, its duration 



HAY FEVER, OR VASOMOTOR RHINITIS. 123 

not being given. An analysis of the duration of the disease in my 
own eighty cases is as follows : 

From May 1st to frost, . • 1 

" 15th-25th to July 1st, 3 

" . " 10th to August 1st, 1 

" June 1st " July 1st, 2 

" 1st " " 14th, 1 

" " 1st " frost, 5 

" 10th " July 4th, 4 

" 10th " " 26th, 5 

" July 1st " Sept. 1st, 1 

" 10th " Aug. 1st, 1 

" 10th " Sept. 1st 1 

" 25th " frost, 4 

" August 10th-27th to frost, 51 

Total, 80 

A mere glance at these figures, I think, shows conclusively the 
futility of any attempt at a close classification. Furthermore, it is 
impossible to assign any special pollen as the active irritant in any 
of the above classes, inasmuch as definite facts of this character could 
be ascertained only by very close personal experimentation and 
observation, and of this few rmtients are capable. It should be added, 
moreover, in regard to these cases, that it is exceedingly difficult to 
elicit an accurate clinical history from the patients without close 
questioning, and even then the principal points of the histories 
which an inquirer desires to ascertain are but vague impressions; 
hence their answers will be of a very general and indeterminate char- 
acter, based on an imperfect recollection of their last annual attack. 

The above figures refer to the disease as manifested in America. 
In England it usually appears in May and June and rarely lasts into 
September. The same is true of France, Germany, and other Euro- 
pean countries. The autumnal variety of the disease would seem then 
to be exclusively American. An interesting question in this connec- 
tion arises as to whether the disease is not greatly on the increase. 
Personally, I am inclined to think so. This belief is based not only 
on the fact that a larger number of cases come under my own per- 
sonal observation each year, but on the increased severity of the 
symptoms observed to develop year by year; as, in many instances, 
a patient hitherto suffering from a mild rose cold in the early 
summer will now have in addition an autumnal attack; and, further- 
more, patients hitherto suffering merely from the influenza commence 
now to suffer, in addition, from hay asthma as well. 

It might be stated here, in regard to my own cases, that they 
are entirely made up of patients in my own private practice, and, 



124 DISEASES OF THE NASAL PASSAGES. 

furthermore, that whereas I have reported but eighty, quite a large 
number are not included, owing to the fact that the recorded histories 
are incomplete. 

Geographical Distribution of the Disease. — Wyman attempted 
to show that the disease was limited to certain areas. A larger 
familiarity with the disease, I think, demonstrates that Wyman' s 
conclusions were based on insufficient research, and that we shall find 
hay fever prevalent throughout the whole United States, with the 
exception of certain elevated districts, such as the White Mountains, 
the Adirondacks, and a portion of the Southern States. That the ter- 
ritory west of the Mississippi is to a certain extent exempt is 
explained by Beard on the ground of the lack of vegetation, and the 
sparsity of population in these immense districts. This immunity, 
however, is disappearing rapidly each year, as there is nothing in 
the flora or the climate of the West which affords exemption from the 
disease, for, as population extends, and urban life increases, the 
diseases of civilization become more common. 

It is also a noticeable fact that some parts of the White Moun- 
tains which have hitherto been classed among the exempt regions 
have failed in late years to give that complete relief which patients 
have formerly enjoyed there. This is probably due to the extension 
of the railroads, which have increased the amount of travel and, as a 
consequence probably, extended to a degree the flora of the valleys. 

Diagnosis. — The disease, it is well known, is not infrequently 
looked upon as summer cold and its periodicity overlooked. A 
mistake in diagnosis, however, need never be made, for there are 
certain characteristics which distinguish it in a marked way from an 
ordinary attack of acute rhinitis. These are the comparative sudden- 
ness of its onset, as well as its disappearance, together with the 
peculiar symptoms which characterize its progress, which are the 
violent sneezing and profuse watery discharge. Now, in an ordinary 
acute rhinitis, the stage of the disease which is accompanied by a 
serous discharge from the nose is of comparatively short duration, 
whereas in hay fever this feature of the disease continues during the 
whole course of the attack. Moreover, in a cold in the head, intense 
sneezing lasts but a few days and does not occur in the violent 
paroxysms characteristic of hay fever. The appearances of the mem- 
brane on examination, moreover, are totally distinct in the two 
affections. In acute rhinitis the membrane is red, highly congested, 
and pours forth a more or less profuse mucous or muco-pus discharge, 
in connection with the serous exudation, which is seen coating its 
surface in yellowish semi-opaque flakes or masses. In hay fever, on 
the other hand, the membrane, although swollen, never presents the 



HAY FEVER, OR VASOMOTOR RHINITIS. 125 

bright-reel appearance of an acute inflammation, but is of a bluish- 
gray tinge, verging on opalescence. This is due to the fact that the 
hyperemia is confined entirely to the large venous sinuses which 
comprise the turbinated bodies, the capillaries of the mucous 
membrane proper not being congested. In addition to this, the 
surface of the membrane is covered with slightly viscid watery serum, 
which gives it a glassy semi-translucent aspect. The swollen con- 
dition of the membrane gives rise to more or less complete occlusion 
of the nasal cavity, the turbinated bodies lying in contact with the 
septum. At these points of contact, little bridges of viscous serum 
will be noticed stretching across from one side to the other, giving 
the appearance of air bubbles as it were. Posterior rhinoscopy adds 
little to our information, other than showing the posterior nares 
occluded by the swollen grayish membrane covering the turbinated 
bodies posteriorly. Suffusion of the eyes, with photophobia and 
epiphora, afford a certain amount of diagnostic information, although 
those may occur in connection with an ordinary cold in the head. 

Prognosis. — Hay fever rarely involves any marked impairment of 
the general health, and hence the prognosis is never grave. The 
main question of interest, however, is whether the disease can be 
cured. It is a noticeable fact in the voluminous literature on this 
subject that this feature of the diseasse has received but slight con- 
sideration. In a certain proportion of cases the disease seems to 
disappear spontaneously, from no apparent cause. This tendency 
is, however, manifested in but a small proportion of cases. As before 
noted, eighty cases have come under my personal observation and 
treatment, while four additional cases have come under treatment for 
a diseased condition of the upper air passages, who had in previous 
years suffered from annual attacks of hay fever. This perhaps will 
fairly represent the proportion of cases in which we may expect this 
spontaneous disappearance of the affection. In discussing the ques- 
tion of causation, eighty cases were analyzed in which the disease 
was periodical, and the histories fully ascertained. I have, however, 
comparatively full records of one hundred and twenty -one cases. Of 
this number there were : 

Cured, 51 

Relieved, 43 

Unrelieved, 13 

Results unknown, 14 

The above tables embrace all the cases of vasomotor rhinitis that 
have come under my observation, including not only the periodical 
cases, such as autumnal fever and rose cold, but a large number of 
patients in whom the symptoms were perennial. Roe presents 



126 DISEASES OF THE NASAL PASSAGES. 

statistics even more favorable than these, in that of forty -four cases 
under treatment thirty -six were cured, although in sixteen of the 
thirty-six there was some return of the symptoms. 

The duration of the disease apparently has no influence on the 
prognosis, for the case of a year's standiog will often prove quite as 
obstinate to treatment as one of twenty or even thirty years' standing. 
We would naturally suppose that where hay fever has led to the 
development of hay asthma, the neurotic habit was so firmly fixed in 
the individual as to render the prognosis more grave ; and yet this is 
not true, as is shown by an analysis made by the writer of eighty 
cases of asthma. Thirty-four of these cases were of hay asthma, and 
of these eighteen were cured, fourteen relieved, one was lost sight of, 
and in one treatment was apparently without effect. The prognosis 
in hay asthma would therefore seem to be more favorable even than 
in hay fever. Age, I think, has an undoubted influence on prognosis, 
in that for younger patients a more favorable prognosis can be given. 

We are not warranted in giving an absolutely favorable prognosis 
in any individual case, and yet I think statistics justify us in the 
expectation that a large proportion of cases can be cured. 

Teeatment. — The treatment of hay fever consists in: 

First. — General treatment, for the correction of the neurotic habit. 

Second. — Local treatment, for the relief of the diseased condition 
of the upper air passages. 

Third. — The treatment of the exacerbation. 

First. Constitutional Treatment. — The efficacy of internal medica- 
tion was recognized very early in the history of this disease, and the 
list of drugs which we find recommended for the correction of the 
neurotic habit embraces a large proportion of the so-called nervines, 
as well as many of the anodynes. Among these we include belladonna, 
zinc, arsenic, phosphorus, strychnine, hydrocyanic acid, valerian, 
assafcetida, musk, lobelia, amber, the bromides and iodides, chloral, 
opium, hyoscyamus, quinine, and the various preparations of iron. 

The usual method of administration of these drugs is to commence 
with small doses from two to four weeks before the annual attack sets 
in, gradually increasing the dose to get the patient thoroughly 
under the influence of the drug by the time the paroxysm comes on, 
and to continue its administration while the attack lasts. Long before 
the essential pathological lesion which characterizes an attack of hay 
asthma was recognized, the use of belladonna was resorted to as an 
antispasmodic. That belladonna exercises a notable influence in 
controlling the manifestations of this disease has been confirmed by 
most observers. Dechambre advised that it should be given in grad- 
ually increasing doses until its full physiological effect was obtained, 



HAY FEVER, OR VASOMOTOR RHINITIS. 12? 

after which the doses should be slowly decreased. This, however, 
was during the attack. Better results I think are obtained by com- 
mencing the administration of the remedy three or four weeks before 
the attack, and continuing it until its termination. Mackenzie has 
found " valerianate of zinc in combination with assaf cetida more val- 
uable than any other drug." He commences with the administration 
of one grain of the zinc, in combination with two grains of compound 
asafcetida pill, before the attack comes on, and at the end of two 
weeks doubles the dose. I fully believe in the therapeutic value of 
the salts of zinc in this affection, but regard belladonna as far more 
efficacious and certain in its action. No combination in my own 
experience has been attended with better results than the administra- 
tion of both these remedies as in the following : 

3 Zinci pbospbidi, gr. viij. 

Extract, belladonnas, gr. x. 

M. ft. mass, in pill. no. xl. div. S. One pill tbree times a day after eating. 

Most cases of hay fever show no evidence of impaired nutrition, 
but, on the contrary, I think the rule is that they present every evi- 
dence of vigorous general health. When, however, there is evidence 
of impaired nutrition, I think the administration of arsenic is often 
attended with the best of results, and in these cases the above for- 
mula can be amended as follows : 

I£ Zinci pbospbidi, • gr. viij. 

Acidi arseniosi, gr. i. 

M. ft. mass, in pill. no. xl. div. S. One pill after eacb meal. 

Or, again, in certain cases I have combined the three drugs in the 
same prescription in the above proportions. 

As noted above, most writers tell us to commence the administra- 
tion of constitutional remedies three or four weeks before the hay-fever 
season. This is not the time, as a rule, when the patient comes 
under observation ; in fact, I think in most instances they come during 
the attack, or just after it ; and this it seems to me is by far the better 
time to commence treatment, for, as already intimated, I regard local 
measures of treatment as of more importance than constitutional. I 
think, therefore, the time to administer internal remedies for the 
correction of the general habit is at the same time at which our local 
treatment is instituted. The general neurosis which requires correc- 
tion exists during the whole year, and certainly, if the case is one of 
autumnal fever, the winter or early spring months are quite as 
favorable to commence treatment as midsummer. If one were to 
choose the season, however, for treating these patients, I think perhaps 
the preference might be given to the early summer months, when the 



128 DISEASES OF THE NASAL PASSAGES. 

warm dry atmospheric conditions are at least unfavorable to catarrhal 
disease involving the upper air passages. As regards the other 
drugs of the long list above enumerated, I have but limited experience 
and little faith in their value. 

There are certain general hygienic measures, which are of un- 
doubted importance, such as the regulation of the clothing and the 
habits of life. These have already been sufficiently elaborated in 
previous chapters. There is, however, one measure which I regard 
as of the greatest importance. This consists in the use of the cold 
douche on the spine. A sponge bath is not sufficient. The end to be 
accomplished is the general tonic effect on the central nervous system 
which is produced by the sudden and decided shock of cold water 
down the spine. The cold shower bath accomplishes the purpose in 
an admirable manner, and yet this is not always tolerated by the 
patient. I have rarely, however, seen a patient who could not 
endure easily the cold douche confined to the spine alone. 

Such other treatment as may be required during an attack is 
simply that which would be suggested by the general laws which 
govern the administration of drugs for the control of such symptoms 
as may be presented. Of these opium is undoubtedly the most 
valuable, both to allay the nervous irritability and for procuring 
sleep. Mackenzie gives preference to the tincture over any other 
preparation, giving small doses, of from five to seven drops, twice 
daily. This, however, as a rule, should be governed by the tolerance 
and preference of the patient. In many cases, the best action of the 
drug would be secured by the hypodermatic administration of mor- 
phine, as recommended by Moorhead, who first used in this manner 
-^ of a grain of morphine, with -^j- of a grain of atropine twice daily, 
but subsequently found his best results from the administration of ■£$ 
of a grain of the tartrate of morphine twice daily, increasing the 
dose, as the attack developed, to -^ of a grain three times daily. 

Opium undoubtedly does more than control the general condition, 
in that it goes far to modify the severity of the local symptoms. No 
physician, however, should take the responsibility of administering 
to a patient T V of a grain of morphine three times daily through the 
three months of a hay -fever exacerbation without recognizing the 
exceeding great danger the patient incurs of contracting the opium 
habit. While, therefore, opium is undoubtedly among the most 
efficacious of our constitutional remedies during an exacerbation, I 
think it well to depend mainly on less dangerous anodynes, such as 
hyoscyamus, or the bromides, alone or in combination with chloral. 

Second. Treatment of the Diseased Condition of the Upper Air 
Passages. — If the view maintained in discussing the causation of hay 



HAY FEVER OR VASOMOTOR RHINITIS. 129 

fever be correct, that in all cases a powerful predisposing cause lies 
in a diseased condition of the upper air passages, it necessarily 
follows that by far the most important feature of treatment consists in 
the removal of the morbid local lesion. 

The special affections which act as predisposing causes of hay 
fever are hypertrophic rhinitis, naso-pharyngeal catarrh, deflections 
of the septum, nasal polypi, and indeed any obstructive lesion in 
the nose which tends to produce a chronic turgescence of the blood- 
vessels. When we include naso-pharyngeal catarrh among the local 
exciting causes of the disease, and as one constituting an obstructive 
lesion, it is to be understood that we refer to the very intimate and 
close sympathy which we find existing between the nose and the naso- 
pharynx, under the action of which a morbid process in the latter 
region seems to act as the immediately exciting cause of a hyper- 
seinic condition of the turbinated tissues, this latter being the directly 
predisposing cause of the hay-fever exacerbation. The special 
indications for treatment are to be sought by careful investigation 
and diagnosis of each individual case, and such lesion as inay be 
found is to be treated according to the rules laid down in a previous 
chapter. If nasal polypi or other tumors are discovered, the}' should 
be extirpated; if a deflection of the septum exists, the obstructing 
portion should be removed. If hypertrophy or chronic hyperemia 
is discovered, these conditions should be reduced in the manner 
already described. In brief, the essential requirements of treatment 
demand that the whole of the upper air tract be restored to a 
condition of normal patency. Sajous, in his interesting monograph, 
takes the ground that the cauterization of the nasal mucous mem- 
brane results in an alteration of superficial nutrition. I am dis- 
posed to think that the excellent results which Sajous obtained from 
treatment were really in subduing turgescence and reducing the hyper- 
trophied membrane. Sajous, writing at a later date, lays special 
emphasis on the necessity of confining his caustic applications to 
the sensitive areas, having previously determined these by means of 
the cold probe, following the method previously described by John 
Mackenzie. The sensitive areas in the nose described by John Mac- 
kenzie I have never been able to definitely locate as such, and still 
adhere to the belief that the indications for treatment are the reduc- 
tion of inflammation and the removal of obstructive lesions, and not 
the control of a hypersesthetic condition in the nose. I think it is a 
more rational view that the success in treatment undoubtedly obtained 
by the advocates of the sensitive-area theory by means of cauteriza- 
tion is directly due to a reduction of inflammation and diminution of 
blood supply. 
9 



130 DISEASES OF THE NASAL PASSAGES. 

Third. Treatment of the Exacerbation. — The early recognition of 
the fact that floating pollen in the atmosphere was the exciting cause 
of the attack led to attempts to protect the mncous membranes from 
its impact. I have never had much faith in the efficacy of respirators 
or veils, and, furthermore, the discomfort of wearing them during the 
whole of the hay -fever season would be so great that many patients 
would prefer to risk the exposure to the pollen. No local remedy 
that has ever been used for the relief of an exacerbation of hay fever 
is comparable to cocaine, both as regards the certainty and prompt- 
ness of its action and the completeness of the relief afforded. I have 
made use of it in cases of hay fever as well as in other nasal dis- 
orders characterized by vascular turgescence, and have found it to 
give complete relief from all the symptoms for the time. This action 
of cocaine in hay fever I attribute purely to its property of contract- 
ing the blood-vessels, for the hay-fever symptoms abate as soon as 
the vascular turgescence is allayed. It has been charged, notably by 
Beverley Kobinson, that after the vascular distention has been sub- 
dued by cocaine the relief is but temporary, and is followed by a 
reaction in which the distressing nasal stenosis is even greater than 
before. I have used the drug very extensively since its introduction, 
and recall but three instances in which any such reaction was observed. 
As before stated, the relief is prompt and efficient, although not per- 
manent, lasting but from two to three hours, when relaxation of the 
blood-vessels occurs, demanding a second application. The formula 
which I usually give is as follows : 

I£ Cocain. hydrochlorat., gr. xx. 

Sodii bicarb., 

Acidi borici, aa gr. x. 

Aquas, I i. 

M. ft. sol. 

This is to be used by means of the small hand atomizer shown in 
Tig. 19 or any small cologne atomizer such as is sold in the drug 
stores. The patient is directed to apply this freely to the nasal cavi- 
ties as often as may be necessary to control the symptoms. The 
above solution, as will be seen, is about a four-per-cent. solution. It 
is well to mention this to the patient, directing him to reduce the 
strength until he finds what, in his own experience, is the weakest 
solution which may be used and still give relief. In many instances 
I have found that even a one-half -per-cent. solution was quite as effica- 
cious as the preparation given above, and of course it is always desir- 
able that the end should be acorn plished with as weak a preparation 
as possible. An excellent method of administering cocaine is as 
follows : 



HAY FEVER, OR VASOMOTOR RHINITIS. 131 

1$ Cocain. hydrochlor., gr. x. 

Aquae, q. s. 

M. ft. sol. 
Adde 

Fluid cosmoline vel 

01. voschano, § i. 

Shake well before using. 

This is to be used in the atomizer shown in Fig. 18. It is 
perhaps a less convenient form than the watery solution, but the 
cosmoline affords a grateful and soothing application to the mucous 
membrane, while the cocaine exercises the same action as in the 
watery solution. Mackenzie recommends the use of gelatin bougies 
containing -^ of a grain of cocaine combined with y^ of a grain of 
atropine. These are to be inserted into the nasal passages by the 
patient, and allowed to remain there until they melt. This method 
of application is uncleanly, and, furthermore, is not thorough. I 
think the application to the middle turbinated bodies is even more 
important than to the lower, and certainly patients suffering from 
hay fever would not tolerate the insertion of a bougie into the middle 
meatus. The same objection, I think, lies against all suppositories 
of cocaine, as well as the gelatin discs and other preparations of the 
sort. Insufflations of powders are not open to this objection and are 
to be recommended as follows : 

I£ Cocain. hydrochlorat., gr. x. 

Bismuthi subcarb., 3 i- 

Magnesias carb. lev., 3ij. 

M. 

Or, 

I£ Hydrarg. chloridi mitis, . . . . . . . gr. v. 

Cocain. hydrochlorat., gr. x. 

Sacch. lac, . 3 iij. 

M. 

The addition of morphine to one of these powders is always grateful 
to the patient, but a combination of morphine with cocaine should 
always be used judiciously. Keeping this in view, the following may 
be used : 

I^ Morphinae tartratis, . . . gr. i. 

Cocain. hydrochlorat., gr. x. 

Sulphuri flor. , 3 ss. 

Sacch. lac, 3 iiss. 

The only objection to the use of a snuff is that we do not, as a rule, 
get the same thorough penetration of the nasal cavities as by means 
of the atomizer. 

The ocular symptoms, being due quite as much to the direct 



132 DISEASES OF THE NASAL PASSAGES. 

impact of the pollen upon the cornea and conjunctiva as to sympa- 
thetic action, are to be relieved by the same local applications which 
are applied to the nasal cavity, although with this proviso, in apply- 
ing cocaine to the eye, the solution should not be stronger than one 
per cent. If, however, the eye is well protected by colored glasses 
in most instances the relief will be such as to render local applications 
unnecessary. Cheatham makes the very excellent suggestion that 
eserine, in the strength of -jV of a grain to the ounce, should be added 
to the cocaine solution in order to prevent the dilatation of the pupil. 



CHAPTER XV. 

ASTHMA, OE VASOMOTOK BEONCHITIS. 

Asthma is a disease characterized by dyspnoea, both inspiratory 
and expiratory . The diurnal character of the disease is shown by the 
recurrence of the attacks at certain times during each twenty -four 
hours, usually at night and lasting for some hours. The seasonal 
character of the attack manifests itself in the disposition of the symp- 
toms to undergo complete relief at certain periods of the year, usually 
the warm dry months of summer, and, in a less degree, the dry cold 
months of winter. 

Etiology. — The first to write a really exhaustive work on asthma 
was Henry Hyde Salter, who makes the following propositions : 

First. Asthma is essentially, perhaps with the exception of a 
single class of cases, a nervous disease, the nerve centres being the 
seat of the essential pathological condition. Second. The phenomena 
of asthma, distressing sensation and demand for extraordinary respi- 
ratory efforts, immediately depend upon spasmodic contraction of 
the cells of unstriped muscular fibre in the bronchial tubes. Third. 
The phenomena are excito-motor or reflex actions. Fourth. The 
extent to which the nervous system is involved differs much in differ- 
ent cases, being, in some, restricted to the nervous apparatus of the 
air passages themselves. Fifth. In a large number of cases, the 
pneumogastric, both gastric and pulmonary portions, is the seat of 
the disease. Sixth. In a large class of cases the nervous circuit 
involves other nerves besides the pneumogastric. Seventh. There is 
still another class of cases in which the irritation is central. Eighth. 
In a certain proportion of cases the irritation is humoral. 

We see, then, that, according to Salter, asthma is essentially a 
neurotic disease, and this theory, with some modifications, is the one 
adopted at the present day. 

The series of phenomena found in asthma is explained by certain 
writers on the theory that the dyspnoea is due to the contraction of 
certain muscular fibres which anatomists have demonstrated as exist- 
ing in the bronchial tubes, down to their smallest ramifications. It 
seems rather curious that this theory should not long ago have been 



134 DISEASES OF THE NASAL PASSAGES. 

questioned. All observers very properly recognize asthma as a neu- 
rotic disease, and muscular spasm is undoubtedly a manifestation of 
the neurotic temperament, and apparently on this trivial ground the 
theory has been accepted. 

In 1872, however, we find the spasm theory called in question, and 
what, to my mind, is a far more plausible one advanced by Weber, 
who was the first to teach us that the cause of the paroxysm lay in a 
paresis of the vasomotor nerves presiding over the vessels of the 
bronchial mucous membrane. Under the influence of this vasomotor 
paralysis there occurs, from some cause, a sudden letting up of the 
control which is exercised over the calibre of the blood-vessels, where- 
upon they become distended to such an extent as markedly to interfere 
with the passage of air through the bronchial tubes. This paralytic 
condition having lasted several hours, the membrane maintaining a 
dry condition, as is always the case in the first stage of the inflamma- 
tory processes, there follows an escape of serum and sero-muciis, thus 
relieving the engorged blood-vessels, which soon regain their normal 
calibre, coincident with the cessation of the paroxysm. We thus 
have a thoroughly rational theory in explanation of the symptoms of 
spasmodic asthma. As to the causes, however, of the disease, little has 
been said, further than the enumeration of the causes already stated, 
as laid down by Salter. Weber's paper, however, was followed by a 
series of clinical observations, which lent considerable weight to his 
theory and also threw much light on the causes of the disease. These 
observations were followed by a large number of similar reports from 
others, and gave rise to discussions on asthma as a reflex disease due 
to nasal polpyi and other nasal disorders.' 

In a paper read before the American Climatological Association, 
May 28th, 1885, I first advanced the view that hay fever and peren- 
nial asthma were virtually one and the same disease, the one being a 
vasomotor rhinitis, the other being a vasomotor bronchitis, the 
paroxysms being excited, in each case, by some peculiar atmospheric 
condition. The atmospheric condition, as we know, in hay fever is 
the presence of the pollen of flowering plants, or some other vegetable 
emanation ; whereas the atmospheric condition in perennial asthma, 
as we may designate those cases of asthma which occur during the 
whole year and do not depend upon hay fever, is dependent upon 
some obscure element which we are, as yet, unable to trace with the 
same degree of definiteness as we are enabled to trace it in hay fever. 
Hay fever is dependent upon three conditions : 

First. A neurotic habit, as was conclusively shown by Beard. 

Second. The presence of pollen in the atmosphere, as shown by 
the unrivalled experiments of Blackley. 



ASTHMA, OR VASOMOTOR BRONCHITIS. 135 

Third. A disordered condition of the nasal passages, as shown by 
Daly. 

Now, the view that I advocate is that asthma also is dependent on 
three conditions : 

First. A general neurotic condition, as demonstrated by Salter. 

Second. A diseased condition of the nasal mucous membrane (not 
the bronchial). 

Third. Some obscure condition of the atmosphere exciting the 
paroxysms. 

The view as regards the neurotic condition is generally accepted ; 
that as regards the atmospheric condition, I think, is one which must 
be generally accepted by all observers, when we consider the diurnal 
and seasonal periodicity of the paroxysms. As regards the nasal 
condition as a predisposing cause of the attacks, the view is a novel 
one, and, naturally, would be looked upon as the hobby of a specialist. 
In my original paper I made this assertion, that " a large majority, 
if not all, cases of asthma were dependent upon some obstructive 
lesion in the nasal cavity. This iti evidenced by the immediate relief 
from the exacerbation by the use of cocaine in the nose in every 
case in which I have tried it, and, furthermore, by the cure of so mam- 
cases by the removal of the obstructive lesion in the upper air 
passages." 

This paper was read some years ago. The views there stated I 
would repeat with even more emphasis, for subsequent clinical obser- 
vation has only served to confirm me in my belief of their correctness. 

In looking over my notes, I find I have recorded histories of eighty 
cases of asthmatics. A prominent feature in the analysis of these 
records is the preponderance of cases which show a decided neurotic 
family history ; twenty -five of the thirty cases of hay asthma being of 
inherited neurotic habit, in which the history is known, while in the 
perennial form sixteen of the twenty-eight cases, in which the history 
is ascertained, show the neurotic tendency. 

The tables also show that the largest number of cases of asthma, 
in both forms, develops during the third decade of life, while no period 
is notably exempt. This differs from Salter, who states that most 
cases develop during the first decade. 

It was noticed that whereas, in hay fever, the seashore afforded 
the greatest relief, after asthmatic symptoms had set in, the same 
rule applied to both forms, and that high altitudes were most bene- 
ficial ; and yet, I think, no rule can be formulated for the cases as a 
class. 

The following, it seems to me, is of the greatest importance, as 
sustaining the original assertion made in the first part of the chapter; 



136 DISEASES OF THE NASAL PASSAGES. 

Hay Asthma. 
Nasal symptoms immediately preceding attack, such as sneezing with 

watery discharge from the nose, 29 

No symptoms preceding attack, ........ 5 

Total, 34 

Perennial Asthma. 

Nasal symptoms preceding attack, 33 

No nasal symptoms preceding attack, 12 

Cutaneous eruption preceding attack, 1 

Total, 46 

It should be mentioned that many patients entirely ignore the 
nasal symptoms, in the greater discomfort arising from the dyspnceic 
attack, and only recall them when their attention is turned in that 
direction. We see, then, that of the eighty cases, the asthmatic attack 
set in with sneezing, etc., in sixty -two. 

Of the eighty cases, fifty -four gave a history of previous catarrhal 
trouble. Yet the testimony of patients in this matter is not to be 
relied upon, as many patients have undoubtedly notable impairment 
of the nasal respiratory function without being conscious of suffering 
from what they call catarrh. Moreover, in a large proportion of nasal 
disorders, the symptoms are referred, by the individual, to the throat, 
while " catarrh" is popularly referred to the nose. 
Intranasal Condition — Hay Asthma. 

Hypertrophic rhinitis, 9 

" " and deflected septum, 12 

Polypi and deflected septum, 5 

Polypi, 4 

Deflected septum, 3 

Elongated uvula, 1 

Total, 34 

Intranasal Condition — Perennial Asthma. 

Hypertrophic rhinitis, . 13 

Nasal polypi, 11 

Hypertrophic rhinitis and deflected septum, 11 

Polypi and deflected septum, 6 

Deflected septum, 3 

Adenoid and hypertrophic rhinitis, 2 

Total, 46 

I have never known a case of hay fever or asthma to occur in other 
than an obstructive lesion of the nose or upper air passages, as will 
be seen by this table ; this was true of every one of the eighty cases, 
including that of the elongated uvula, which became a source of 
respiratory obstruction. 



ASTHMA, OR VASOMOTOR BRONCHITIS. 137 

Treatment — Hay Asthma. 
Hypertrophic rhinitis, treatment by caustics : 

Cured, 7; improved, 6; unimproved, 1. 
Deflected septum, operated on by author's nasal saw : 

Cured, 8 ; improved, 6. 
Nasal polypi treated by snare, without caustics : 

Cured, 2; improved, 1. 
Treatment by snare and septal saw in cases of polypi and deflected septum : 

Cured, 1 ; improved, 1. 
Cases treated by uvulotomy : 

Cured, 1. 

Treatment— Perennial Asthma. 
Hypertrophic rhinitis, treated by caustics : 

Cured, 8 ; improved, 5. 
Polypi treated by snare, without caustics : 

Cured, 15; improved, 3. 
Deflection of septum operated on by author's nasal saw : 

Cured, 3 ; improved, 4 ; unimproved, 1. 
Adenoid growths removed by snare : 

Cured, 2. 

The treatment, as will be seen, has been such as our English 
friends regard as harsh and in many cases unwarranted. I think it 
but justice to say that, in some cases, patients have been unwilling 
to continue on account of this, and yet, with the use of local anaes- 
thesia, these operations are not painful; it is the nervous strain, on 
this class of patients, which has taxed them most serverely. That 
the surgical treatment of nasal diseases is fully justified I think the 
following table amply demonstrates : 

Results of Treatment — Hay Asthma. 

Cured, 19 

Improved, 14 

Unimproved, 1 

Unknown, 

Total, 34 

Results op Treatment — Perennial Asthma. 

Cured, . .28 

Improved, 12 

Unimproved, 1 

Unknown, 5 

Total, 46 

I have thus given all the results obtained from the analysis of my 
cases, as bearing not only on etiology but also on other branches of 
this subject. The point upon which I wish to lay special emphasis 
here is the very close and intimate physiological and pathological 
connection between the nasal mucous membrane and that lining the 



138 DISEASES OF THE NASAL PASSAGES. 

bronchial tubes, and the further fact that in asthma we must look for 
the active predisposing cause of the attack in a diseased condition of 
the nasal mucous membrane. In the above statistics we have included 
hay asthma and perennial asthma, considering these two affections 
as virtually one and the same disease, from a clinical point of view. 
This is shown by the fact that in many instances they are inter- 
changeable, in that a patient may suffer a number of times from hay 
fever without developing asthmatic attacks ; finally, however, his hay- 
fever paroxysm winds up with an attack of true nervous asthma, a 
still further change consisting in the cessation of the hay-fever attacks, 
and the patient becoming subject merely to attacks of perennial 
asthma. This fact I have noticed in quite a number of instances. 

As regards the remote causes of perennial asthma, then, I think we 
must recognize the fact that even in this there must be in many cases 
some local disorder of the nasal cavities which leads to the develop- 
ment of the reflex disturbance ; otherwise the presence of worms in the 
intestinal canal or other disturbing influences would scarcely result in 
the development of an attack of asthma. We have already shown the 
intimate physiological connection between the nasal mucous membrane 
and that of the bronchial tubes, and that a weakened condition of the 
passages above tends to develop a similar condition in the parts below. 
I think, therefore, we must recognize in all these unusual reflexes this 
tendency of vasomotor weakness of the bronchial tubes, under the 
action of which worms in the intestinal canal, undigested food in the 
stomach, and other causes may produce an asthmatic attack. Perhaps 
it would be not wise to say that a pathological intranasal condition 
is present in every one of these cases of obscure reflexes, and yet I 
think it is still less wise to accept evidence of cardiac lesion or of 
gastric disturbance as presenting a sufficient cause of the attack with- 
out also examining the nasal cavities to ascertain whether some 
lesion may not also exist there. 

The disease being essentially a neurosis, we would naturally expect 
to find heredity exercising a notable influence, a fact which all statistics 
fully bear out, in that this disease, as well as hay fever, seems to run 
in families, as it were. The influence of age and sex has already 
been clearly shown in the statistics given. The possible existence 
of a rheumatic or gouty diathesis should not of course be overlooked 
as factors in the development of these attacks. How they should act 
it is impossible to say, and yet, here as before, I still think the pos- 
sible existence of a predisposing nasal disorder should not be over- 
looked. We regard, then, an intranasal disorder as not only a 
powerful predisposing but exciting cause of an attack of asthma. It 
should be stated, however, that when we speak of pathological intra- 



ASTHMA, OR VASOMOTOR BRONCHITIS. 139 

nasal conditions we include not only a diseased condition of the 
nasal cavity but also of the naso-pharynx. 

Symptomatology. — A paroxysm of asthma usually occurs at night, 
and perhaps in the majority of instances during sleeping-hours. A 
patient retires without any premonition of danger and is awakened 
by a most distressing dyspnoea. He springs from his bed, terrified 
and gasping for breath. His face is turgid, eyes protruded, mouth 
open, with the perspiration starting upon his face. The dyspnoea 
is both inspiratory and expiratory ; inspiration being shorter and 
somewhat quicker in that it is aided by all the voluntary and in- 
voluntary muscles of respiration, while the expiration is somewhat 
prolonged in that the patient apparently seeks a momentary period of 
rest, in allowing such air as he has drawn into the lungs to escape vol- 
untarily. Whereas the dyspnoea characterizes both acts of inspira- 
tion and expiration, the muscular struggle is largely expended on the 
inspiratory act. The pulse is ordinarily somewhat rapid and weak, 
especially if the paroxysm is prolonged. The temperature usually 
falls somewhat below the normal, due probably to the fact of insuffi- 
cient oxygenation. This represents a typical and well-developed at- 
tack of asthma which may last for from one to two, three, or four 
hours, and in rare cases may persist from one to three days. When 
the paroxysm comes on during waking hours, in the large majority of 
instances it commences with sneezing and watery discharge from the 
nose, which may be of such a character as to give considerable annoy- 
ance to the patient, or be so slight as to scarcely excite attention. 

In that form of asthma which occurs in connection with hay fever, 
of course, the attacks are confined only to the hay-fever season, but in 
the ordinary form of asthma, which we have already designated as 
perennial, the attacks are usually aggravated by the damp atmosphere 
of the spring and fall, the patient enjoying a certain degree of immu- 
nity during the clear cold weather of winter and the warm weather of 
summer. 

The character of the paroxysm is also notably influenced by the 
changes in weather. In the midst of the bad season the attacks may 
be arrested by a change to a dryer climate, especially to high altitudes, 
where an atmosphere is encountered which seems exceedingly favorable 
in its influence upon these cases. In most of these patients, also, a 
peculiar hyperaasthetic condition of the whole upper air tract is 
present, evidenced by the fact that the presence of irritating vapors, 
dust, gases, etc., will produce a temporary sense of dyspnoea or even a 
well-marked paroxysm of asthma, which, however, usually disappears 
promptly on the removal of the exciting cause. The cessation of the 
paroxysm is usually attended with a more or less profuse sero-mucous 



140 DISEASES OF THE NASAL PASSAGES. 

discharge, the clinical significance of which has already been fully 
discussed in the statement that this is due to the unloading of the 
engorged blood-vessels by a serous exosmosis, by means of which 
their calibre is diminished and thereby the patency of the bronchial 
tubes restored. 

Physical Signs. — On inspection of the chest during a paroxysm, 
the first noticeable feature will be the very marked impairment of 
motion, in that the whole chest wall seems somewhat rigid and to 
move together. This, however, is to an extent deceptive, the limited 
movement of the chest being really due to the limited amount of air 
which is drawn in with each act of inspiration. Percussion simply 
reveals perhaps a slight exaggeration of normal resonance. The 
diagnosis, of course, is based entirely on auscultation, by means of 
which there will be recognized the characteristic sibilant and sonorous 
rales throughout the whole of the chest cavity and heard equally at 
any point. These are blowing, purring, whistling, cooing sounds, 
that are caused by the passage of air through the narrowed tubes of 
various calibres, the walls of which are perfectly dry. In other 
words, there is total absence of any moisture, but the mingling of 
dry rales constitutes a confusion of musical sounds, as it were, which 
can be likened to nothing so much as the cooing of a flock of pigeons. 
So loud are these sounds that they can be heard frequently even 
across the room. The normal respiratory murmur is of course com- 
pletely masked by these loud rales, which are heard both in inspira- 
tion and expiration, although, as before stated, the expiratory sounds 
are somewhat prolonged. At the termination of the paroxysm, the 
dry rales diminish in intensity and to an extent disappear. The 
moist rales may now be heard, as the serum transudes the blood- 
vessels and makes its appearance in the bronchial tubes. 

Pkognosis. — Asthmatic patients are said to be long-lived, which is 
probably true, in that there is nothing in the disease itself which would 
tend to shorten life. During attacks the sufferings of the patient 
are extreme, but during the intervals he enjoys ordinarily the best 
of health, excluding, of course, those cases which are dependent upon 
a chronic bronchitis, which, as before stated, is not to be classified 
with nervous asthma. As regards the disease itself, however, the 
prognosis, of course, depends largely on our ability to control it. 
From the analysis of cases given above it would seem that the plan 
of treatment carried out in these affords us a method of controlling 
the severity of attacks in the large majority of instances, and in a 
very flattering proportion of cases of radically curing the disease. 

Treatment. — The consideration of the treatment of this disease 
naturally divides itself into three heads, namely : 



ASTHMA, OR VASOMOTOR BRONCHITIS. Ul 

1. The treatment of the local predisposing cause, which-, as we 
have endeavored to show, consists of a morbid condition of some por- 
tion of the upper air tract. 

2. The treatment of the paroxysm. 

3. The constitutional treatment, or the treatment of the general 
neurotic habit. 

The Treatment of the Local Morbid Condition in the Upper Air 
Passages. — We place this first in importance, in that, as has already 
been intimated, we regard these measures not only as the first to be 
instituted, but as those which promise the best and surest results, and 
even in those cases in which local treatment fails to thoroughly relieve 
the disease we certainly have prepared the way for the better action 
of general remedies. In resorting to these local remedies, we search 
not only the nasal cavities but the cavity of the naso-pharynx for 
the local predisposing cause, but the measures of treatment are to be 
first directed to the nasal pasages proper, for the reason that, as has 
already been intimated, we find in the large proportion of cases that 
the morbid condition of the naso-pharynx disappears upon the resto- 
ration of the nasal passages to a healthy condition of patency and its 
lining membrane to a normal condition of functional activity. 

The Treatment of the Paroxysm. — I have endeavored, in a former 
chapter, to make clear the intimate sympathy which exists between 
the nasal and bronchial mucous membrane, and to show how a pleth- 
oric condition in one region is exceedingly prone to be acccompanied 
by a similar condition in the other. A large clinical experience has 
shown me that we possess few remedies more active or more certain in 
their action than cocaine. This, therefore, should be our first resort. 
It may be applied by means of the small atomizer, shown in Fig. 19, 
or, failing this, an ordinary dropper answers an excellent purpose, a 
small amount being applied to each nostril and repeated every five 
minutes until relief is afforded. In my own hands, I have seen but 
few cases in which this remedy was not notably successful. 

Next in importance to this, we should place datura stramonium. 
This drug is used by burning the leaves and inhaling the smoke, this 
procedure being accomplished by smoking the leaves in a pipe, or in 
the form of a cigarette, or simply by burning them on a plate. 
Clinical experience, however, teaches us that the fumes of the leaves 
have a very powerful effect in controlling the distressing features of 
an asthmatic paroxysm, and, although probably, in the majority of 
instances, they fail to afford perfect and entire relief, they rob the 
attack of much of its distressing character. 

Another remedy of great efficacy is the fumes of burning saltpetre. 
While perhaps not so efficacious as the stramonium, the saltpetre is a 



142 DISEASES OF THE NASAL PASSAGES. 

remedy which rarely fails to afford a certain amount of relief. The 
combination of these two remedies is one which enters largely into 
the manufacture of a large proportion of the asthma remedies sold in 
the drug stores. 

Still other remedies which possess a certain amount of popularity 
for use in this manner, are datura tatula, datura fatuosa, metel, 
belladonna, opium, hyoscyamus, arsenic, etc. These, however, are 
generally used in combination with the stramonium and potash, as in 
the well-known Espic's cigarettes. 

It is a curious feature in the clinical history of asthmatics that 
the efficacy of every remedy seems to exhaust itself, to a certain extent. 
This is not due, I think, to any tolerance produced by the drug, but 
rather to the fact that the longer the disease lasts, and the more fixed 
the asthmatic habit becomes in an individual, the greater the difficulty 
in affording relief to a paroxysm. In other words, the morbid lesion 
which constitutes a paroxysm being a relaxation of the blood-vessels, 
their tonicity or power to recontract seems to be lessened, according 
as the disease persists for a lengthy period of time. Hence, any of 
the above simple remedies may occasionally fail to afford relief, and 
it will become necessary to resort to internal medication. Of internal 
remedies, undoubtedly the most efficacious is opium. This should 
be administered, when necessity demands, in the form of morphine 
and given hypodermatically, as securing the promptest effect of the 
drug, in doses of one-eighth to one-sixteenth of a grain, repeated 
hourly until relief is afforded. Chloral in doses of fifteen to twenty 
grains, repeated every three hours until sleep is produced, or in 
twenty to thirty grain doses repeated twice during the night, will 
usually give relief, especially if combined with an equal amount of 
bromide of potassium. If the paroxysms be very severe, we may 
resort to the administration of chloroform or ether, although these 
remedies should be used with a certain amount of hesitation and with 
the anticipation of giving but temporary relief. The latter is especially 
objectionable, on account of its peculiar irritating action upon the 
mucous membrane of the upper air passages. The use of nitrite of 
amyl has fallen into disuse, on account of the very distressing symp- 
toms referable to the head to which it gives rise. In the same 
category we may place the iodide of ethyl. 

The use of the galvanic current has been recommended for the 
relief of the asthmatic paroxysm by Caspari, and it is an excellent 
suggestion, although scarcely available in most instances. We have 
thus given, somewhat in the order of preference, the various measures 
to which we may resort in our attempts to relieve the paroxysm, all 
of which undoubtedly possess notable merit, and yet, as a rule, I 



ASTHMA, OR VASOMOTOR BRONCHITIS. 143 

think we shall secure, in most instances, the best results from the 
simple measures first enumerated, notably the local application of 
cocaine and the inhalation of the fumes of stramonium and nitrate of 
potash, in some one of their various combinations. 

General Treatment. — While I believe the local treatment of a dis- 
eased condition of the air passages the most important part of our 
therapeutic measures, none will question the marked effect of the 
internal administration of drugs in this disease. Hence I think we 
are rarely justified in depending entirely on local measures alone, 
but when our patients first come under observation they should be 
immediately put on a course of internal medication also. Of internal 
remedies, the one experience has shown us to possess the most notable 
efficacy in the control of asthma, is undoubtedly iodide of potas- 
sium. The best plan for its administration is to give ten grains well 
diluted in wine or water, three times daily after meals for from five 
to seven days, after which the dose may be doubled and continued 
for an equal period. When iodism is produced, as evidenced by the 
metallic taste in the mouth, the dose should be reduced to seven grains 
three times a day for a somewhat long period of time, occasionally 
interrupting its administration for a day or two, but still continuing 
to give it for a prolonged period, or until its efficacy has been thor- 
oughly tested. In late years there have come into use two remedies 
which possess noted value ; these are grindelia robusta and quebracho. 
We find, however, that the constitutional treatment of this disease 
will depend, so far as internal medication is concerned, largely upon 
the administration of iodide of potassium, after the manner above 
detailed. 

Our systemic treatment, however, is not necessarily confined to 
the administration of drugs, for very much can be accomplished by 
certain general hygienic rules. The most important of these is the 
daily use of the cold bath, either in the form of a plunge or shower, 
or, when this is not tolerated, the daily sponging of the skin. In 
addition to this careful attention must be paid to those general rules 
of living which have already been clearly indicated in the chapter 
on hay fever, such as the regulation of the clothing, a certain amount 
of outdoor life and exercise, attention to diet, etc. 

Asthma is not one of the diseases wherein we can give an absolutely 
favorable prognosis in all cases. Hence, our therapeutic resources 
failing, our final resort will consist in advising our patient to seek 
relief in change of climate. Unfortunately, asthma is, moreover, a 
somewhat fickle disease, and hence a climate which is favorable in one 
case will prove unfavorable in another, and we may be at times 
somewhat at a loss just what advice to give. In general, however, 



144 DISEASES OF THE NASAL PASSAGES. 

we may say that those cases of asthma which are associated with 
hay fever will find the greatest relief by residence at the seashore, 
while those which are purely neurotic, such as we have termed cases 
of bronchial asthma, will seek mountainous resorts or high altitudes. 
Why high altitude should prove beneficial in these cases it is difficult 
to say; but certainly clinical experience teaches us that the best 
climate for the purely nervous asthmatic is that of the mountain 
regions. Thus we find that asthmatics do well in the White Moun- 
tains, the Adirondacks, Catskills, or in any elevated region, although 
complete relief is obtained, probably, only at an elevation of between 
3,000 and 4,000 feet. This we find in Colorado, which affords a 
climate better adapted for the larger number of cases than any other 
region, probably, in this country. It should be said further, in 
regard to the effect of climate, -that, whereas relief is obtained imme- 
diately upon our patients resorting to these regions, and that it 
continues so long as they remain there, yet the disease is not cured, 
for they become, as a rule, again subject to their asthmatic attacks 
as soon as they return to the Ipwer level. 



CHAPTER XVI. 

NASAL HYDKOKKHCEA. 

This is a term which we use to designate a curious form of disease 
affecting the nasal passages which is occasionally met with. The 
prominent symptom consists of a profuse watery discharge from 
the nose, which, while presenting many of the symptoms of an ordi- 
nary attack of hay fever, occurs at all seasons of the year. There 
is, however, a certain element of periodicity about it, in that, while 
occurring every day, in many instances it comes on only at certain 
definite times each day, though in other instances it seems to persist 
during the whole twenty -four hours. 

The disease is an exceedingly rare one, and we find but few in- 
stances recorded in medical literature. 

The following cases have come under the author's observation: 

Case I. — Dr. H , aged 58, came under my observation in June, 1882, 

with the following history : Two months previously he caught what ap- 
peared to be an ordinary cold, characterized by nasal stenosis, sneezing, and 
watery discharge, but these had continued ever since, apparently in a peri- 
odical manner as follows : He wakens every morning quite free from every 
symptom, but usually about 9 o'clock there comes on a feeling of formi- 
cation about the bridge of the nose, followed by intense sneezing and profuse 
discharge. It always comes on very suddenly, and persists for from three 
to six hours, although during the remainder of the day he is not entirely free 
from his symptoms. Occasionally, although rarely, the attack intermits a 
single day. The discharge seems to be of an absolutely pure watery charac- 
ter, and in the course of a daily seizure amounts to several ounces. Exam- 
ination showed it to contain a small amount of chloride of sodium, with 
traces of phosphates and lime. This gentleman was seen occasionally, for a 
period of several years, during which time he was subjected to various plans 
of internal and local treatment, until the fall of 1884, when the discovery of 
cocaine placed in his hands a measure which gave more relief than anything 
which had previously been used, and to this day he has continued the use of 
this drug, securing such relief as it affords, now a period of five years. 

When I first examined this patient, two months after the onset 

of his disease, I found no notable evidence of any chronic lesion of 

the nasal cavities, although subsequently he developed ordinary 

mucous polypi in the nasal chambers, which for the time seemed to 

10 



146 DISEASES OF THE NASAL PASSAGES. 

aggravate his symptoms, and the removal of which gave a certain 
amount of relief, although limited. 

The development of the polypi was undoubtedly due to the fact 
that the mucous membrane became sodden and infiltrated with serum 
in its escape from the turbinated tissues. In other words, it became 
so far water-soaked, as it were, as to lead to myxomatous degene- 
ration. A certain amount of relief was given by the application of 
the galvano-cautery to the turbinated tissues; the action of this 
remedy being due to the fact that the superficial cauterization de- 
posited, as it were, upon the surface of the membrane a superficial 
and inelastic coat, which temporarily gave support to the blood- 
vessels and for a time arrested the serous exosmosis. A full trial 
of a continuous current in this case was made without relief, although 
a stronger current than that afforded by seven cells was not tolerated 
by the patient, on account of the severe pain. 

Case II. — Observed by the author. Dr. D , aged 40, consulted me on 

April 7th, 1882, with the following history : For twelve months he had suf- 
fered from a profuse watery discharge from the nose, which had been a source 
of such distress to him as almost to incapacitate him for business. The dis- 
charge was not persistent through the day, but came on usually twice, viz., in 
the morning at 8, lasting about one hour, and again in the evening, from 5 to 
6. The appearance of the discharge was preceded by a sense of intense for- 
mication about the bridge of the nose, followed soon by the dropping. The 
amount during the hour usually was about one ounce. On damp days, how- 
ever, the discharge was persistent throughout the whole day, when its amount 
was usually a pint. With few exceptions, the discharge ceased during the 
night. Dry hot weather seemed to give relief. There was a history of inter- 
mittent fever twenty years before, and again eight years before. Up to twelve 
months before consulting me, he had been a sufferer from facial neuralgia. 
This, however, ceased with the setting-in of the discharge. An examination 
showed his nasal cavities to be in a state of perfect health. The discharge 
was a clear white watery fluid, of a salty taste and feebly alkaline, and con- 
tained a small amount of chloride of sodium, as shown by chemical test. I 
advised the use of quinine, which he took to the extent of ten grains each night, 
for three weeks, with the result of absolutely arresting the trouble. A week 
after, however, he ceased the use of the drug, and the discharge commenced 
again. He resumed his quinine, now without the slightest effect. During 
the following summer, he had an additional daily attack of an hour's dura- 
tion, from 12 to 1 o'clock. At this time he tried the effect of various reme- 
dies. Atropia seemed to aggravate the difficulty. Townsend's remedy was 
absolutely of no avail ; tincture of elfrasia (a homoeopathic remedy for hay 
fever) seemed to give notable relief for a time, in doses of eight minims every 
four hours. Ergot, in combination with digitalis, also was used without 
avail. In the fall he commenced to suffer at night for the first time, and, as 
the cooler weather set in, he resumed the use of quinine with a certain amount 
of relief, although the continuance of his attack seemed now to have a nota- 
ble effect on his nervous system, and he commenced to suffer from extreme 



NASAL HYDRORRHCEA. 147 

mental depression. Occasional doses of quinine now seemed to relieve him 
during the fall months, and on through the winter. The subsequent history 
of this case consisted in a certain amount of relief from the occasional use of 
quinine, and the trial of various other remedies without effect, until on Feb- 
ruary 1st, 1884, he commenced the use of the galvanic current from a battery 
of ten cells, with very marked relief, an electrode being applied on either 
nasal bone. This was continued until July 20th, N with the result apparently 
of curing him entirely. At this time he went to the mountains, and while in 
Saratoga he had an attack of a very severe character, lasting the whole day. 
He immediately returned home, and resorted to the use of electricity with- 
out avail, and in despair concluded to abandon all treatment, when at the 
end of a few days the discharge ceased as suddenly as it had come on, since 
which time he has enjoyed entire immunity from the affection. Lichtwitz re- 
ports a case in which the flow had existed intermittently for twenty-nine years. 
It was cured by puncture of the right frontal sinus. Lichtwitz agrees with 
the author as to the cause of the disease. 

It is interesting to note, in connection with this case also, that 
after the disease had persisted for something over a year mucous 
polypi developed in the nasal cavities, which had heretofore been 
entirely healthy, due solely, as suggested in the previous case, I 
think, to the profuse escape of watery fluid into the mucous mem- 
brane. The presence of these growths did not seem to notably in- 
crease the discharge, nor did their removal seem to ameliorate the 
symptoms. It should be stated that this patient, in addition to the 
use of electricity, subjected himself to a systematic course of Turkish 
baths followed by the cold sponge, together with vigorous massage 
three times each week, during a considerable period of time, in con- 
nection with the electrical treatment. 

In addition to the above two cases, which came under my own ob- 
servation, I have in my notebook live others, the details of which, 
however, are somewhat meagre and are scarcely worthy of record, 
other than as illustrating the fact that this disease is by no means so 
rare as one would suppose, when we consider the small number of 
cases that have been reported in current medical literature. Of these 
five additional cases, one was a maiden lady, aged forty, engaged in 
literary life, and of a decidedly neurotic temperament, whom I saw 
but once. The second was a young lady of twenty-eight, in the en- 
joyment otherwise of fairly good health, in whom no treatment was 
of any avail, although under occasional observation during a period of 
two years. The third was a- physician of about forty, whom I saw 
but once, and who suffered from hay fever during four months, while 
during the rest of the year he suffered from almost daily attacks of 
watery discharge from the nose, which was aggravated by intense 
cold, wind, dust, etc. The fourth was a gentleman aged fifty-one, 
who had suffered for a year with daily attacks, coming on early in 



148 DISEASES OF THE NASAL PASSAGES. 

the morning, from one to four o'clock, and lasting several hours, dur- 
ing which time there was discharged about half a pint of clear watery 
fluid. This patient I saw but a single time. The fifth was a maiden 
lady, aged thirty -five, whom I have seen but twice, and who consulted 
me in regard to a watery discharge from the nose, attended with vio- 
lent irritation and sneezing, and which came on daily, lasting two or 
three hours at a time. 

Etiology. — After a careful examination of the cases it would 
seem no easy matter to give an explanation of the phenomena which 
they manifest, other than purely speculative, and yet I think there is 
much that is exceedingly instructive. The first feature which strikes 
us perhaps is the fact, that in a certain class of cases, the escape of 
watery fluid is merely passive and painless, while in the other the 
flow of water gives rise to symptoms of intense irritation, such as we 
observe in ordinary cases of hay fever. This one symptom will serve 
to divide these cases, then, into two classes. In the first of these 
the essential lesion consists of an ablation of function of the trifacial 
nerve, which, as we know, exercises an inhibitory action upon the 
serous exosmosis which takes place normally in the nasal mucous 
membrane. In connection with the paralysis of this nerve, of course, 
there occurs paralysis of sensation, and henceforth the transudation 
of fluid takes place without consciousness on the part of the sufferer. 
This feature was particularly noticeable in a case of Althaus', in 
which the pathological lesion seems to have been thoroughly recog- 
nized, and the diagnosis established, of neuritis involving the fifth 
nerve of both sides. The question arises whether the disease is due 
to a neuritis, as in this case, or to some other lesion affecting either 
the nerve trunk or the central ganglia, as in two cases of Priestly 
Smith's. In a case of Paget's, an autopsy revealing the existence of 
polypi in the antrum of the side affected, these were accepted without 
question as the cause of the watery discharge. A more rational view, 
it seems to me, is that the polypi were the result of the affection, and 
that the essential lesion consisted of some obscure condition at the 
base of the brain, which gave rise subsequently to an attack of acute 
meningitis, to which the patient succumbed. Certainly it is difficult 
to understand how the existence of polypi in an antrum should cause 
the symptoms, while, on the other hand, it is very easy to see how a 
vasomotor paresis with profuse watery discharge should give rise to 
mxyomatous degeneration, whether in the antrum or in the nasal cav- 
ity, in the same manner as occurred in two of my own cases. In 
another class of the cases, we see that the watery discharge gives rise 
to an intense irritation of the nasal mucous membrane, as manifested 
by the peculiar formication and sneezing, which becomes a source of 



NASAL HYDRORRHCEA. 149 

exceeding great distress. This, of course, can only occur in cases 
in which the general and special sensibility of the Schneiderian mem- 
brane is intact, or in other words, in cases in which the integrity of 
the trifacial nerve is preserved. We must, therefore, seek for a 
cause of the hydrorrhcea in these cases, in some lesion other than 
of the trifacial. We content ourselves with the statement that this 
lesion consists of some disturbance or irritation involving the sym- 
pathetic system of nerves. Whether it is peripheral or central, 
can only be a matter of speculation. It is a noticeable fact, in these 
cases, that there is no evidence of cerebral disturbance whatever, other 
than an occasional headache, which is relieved by the setting-in of 
the watery discharge. The headache is easily explained, in that it is 
probably an ordinary plethoric headache, which is relieved by the 
local exosmosis, in much the same manner as we frequently see head- 
aches relieved by the relief of nasal hyperemia. This latter class of 
cases, therefore, is very closely analogous to ordinary cases of hay 
fever. Moreover, we see in them a certain diurnal periodicity, which 
would seem to indicate that the causes which act to produce the symp- 
toms are operative only under certain atmospheric conditions. In a 
number of these cases, the membrane seemed to be exceedingly sensi- 
tive to the action of cold, wind, dust, or other irritants, thus manifest- 
ing a condition which is almost always present in hay fever, in that 
a large majority of patients who suffer from autumnal attacks of this 
disease are peculiarly sensitive, at all seasons of the year, to the 
action of smoke, dust, or irritating vapors. Sex would seem to have 
but little influence on the affection. It belongs essentially to adult 
life. Traumatism, as a possible remote cause, is mentioned in several 
of the histories, although a careful reading of the cases fails to es- 
tablish any clinical connection between the injury and the hydror- 
rhcea. The neurotic element seems to have been present in many of 
the cases quoted by writers on the subject, in much the same way as 
we find it in hay fever, which brings us to the question as to what 
relation the one disease bears to the other. Certainly, as regards the 
cases dependent on lesion of the trifacial, I doubt if there is any con- 
nection, but in those in which the trifacial was not involved, and 
which we refer to some obscure lesion of the sympathetic, I think 
there can be no doubt that the disease is very closely allied to hay 
fever, in that it is dependent, to a large extent, on what we call the 
neurotic habit. The other two essential causes of hay fever, viz., a 
diseased condition of the nasal mucous membrane, together with the 
impact upon it of the pollen of flowering plants, are not present. In 
my own cases, no lesion was found in the nasal cavities. We can 
only say, then, of these cases, that in connection with an intensely 



150 DISEASES OF THE NASAL PASSAGES. 

neurotic temperament the nasal mucous membrane is rendered sensi- 
tive to some obscure atmospheric condition, under the action of which 
vasomotor control of the blood-vessels, whose special function is the 
exosmosis of serum in the normal process of respiration, becomes 
paralyzed, and that this exosmosis takes place to an abnormally large 
extent. Under the term neurosis, of course, in our ignorance of es- 
sential pathological lesions, we must include some probable organic 
lesion of the nerve trunk or of the ganglionic centres of the sympa- 
thetic system. That there is an atmospheric condition which excites 
the attacks in some instances I think we must accept on clinical 
grounds, in that they occur daily, at about the same time, and in each 
individual case persist for the same period. This view is, further- 
more, strengthened by the fact that dampness, heat, and other 
atmospheric conditions have a marked influence in aggravating or 
alleviating the severity of the symptoms. 

Symptomatology. — The symptoms of the affection consist essen- 
tially in a dropping of clear, transparent, watery fluid from the nose, 
which may come on either gradually or abruptly, and while it lasts, 
consists of a constant flow of water from the nostril, which may be 
attended by a violent sense of irritation or not, according as the 
disease is dependent upon a morbid condition in the sympathetic con- 
trol of the blood-vessels of the nasal mucous membrane or of the 
trifacial. This dripping may continue during the whole twenty-four 
hours, or it may manifest a certain diurnal periodicity. When it 
occurs during the night, it is usually somewhat diminished, although 
in many cases it continues during the sleeping-hours, accumulating in 
the cavity of the nose and pouring out, as it were, on a change of 
position. If it passes into the pharynx, it may give rise to cough, 
or even attacks of spasm of the glottis, or the discharge may be 
poured out upon the upper lip, producing excoriation and ultimately 
almost a cicatrical condition of the skin. If the attack is accompa- 
nied by sneezing, etc. , it may become a source of very great distress 
and even suffering to the patient. When, however, sensation is 
abolished in the nasal cavity, the condition is merely one of discom- 
fort and annoyance, so far as the watery discharge itself is concerned. 

Pkognosis. — In those cases which are essentially neuroses of the 
sympathetic, and which are so closely allied to hay fever, the prog- 
nosis is somewhat unfavorable, in that we have difficulties to contend 
with greater even than those with which we have to contend in 
hay fever. Now, this latter disease, as we know, is an exceedingly 
fickle one, and in many cases will resist every effort to afford relief, 
although we have here a definite local lesion in the nose as a promi- 
nent factor in causation, the removal of which presents a clear 



NASAL HYDRORRHEA. 151 

indication for treatment. In the disease in question, however, the 
only tangible lesion with which we have to deal, is the neurosis, and 
this in most cases will seriously tax our therapeutic resources. Of 
seven cases of this variety which were under my own care, but one 
was cured, although but three of them were under my care for any 
prolonged period of observation. Moreover, in the one case which 
was cured, it is somewhat doubtful whether the fortunate termination 
was the direct result of any therapeutic measures. As regards the 
cases dependent upon a lesion of the trifacial, no prognosis can be 
given, unless the special lesion which has caused the disease can be 
definitely ascertained, in which case the prognosis will be based en- 
tirely on this information. 

Treatment.— The indications for treatment are twofold: first, the 
use of such local applications in the nose as control vascular turges- 
cence, and, second, the resort to such therapeutic resources as we pos- 
sess, for the remedying of the morbid lesion in the nerve trunk. The 
first indication is better carried out by the resort to cocaine, whose 
local action in controlling vascular turgescence is prompt and certain, 
beyond any other drug which we possess. The patient should be 
provided with a proper atomizer, and, commencing with a four-per- 
cent, solution, gradually reduce it, until he finds the weakest solution 
which will afford him relief, when he is allowed to obtain such com- 
fort as may be afforded by its application as frequently as may be 
demanded. I think it is very questionable whether internal remedies 
have proved of much avail. In the second of my own cases, after the 
use of numberless drugs, the patient was finally cured by the use of the 
galvanic current, locally applied, a method of treatment which seems 
in every way rational and apparently clearly indicated, and yet in 
my first case this resort was not only of no avail in giving relief, but 
seemed to aggravate the disease. The best, then, that we can say in 
regard to treatment is that when we can definitely ascertain the 
cause of the disease the indications for treatment are clear. When 
the cause of the disease is obscure, as is the case in the large major- 
ity of instances, any plan of treatment must be to a large extent ex- 
perimental, and governed by such indications as may be found to 
exist upon a careful study of each individual case. 



CHAPTER XVII. 
ANOSMIA. 

Distubbances of the function of olfaction may manifest themselves 
in an increased activity of this sense, giving rise to what is usually 
designated as hyperesthesia. 

Our main interest, however, in this connection, lies in the con- 
sideration of that form of perversion of olfaction which is character- 
ized by an impairment or total loss of the sense of smell, usually 
designated as anosmia. 

Etiology. — This symptom may arise from any condition which 
interferes with the entrance of odorous particles upon the mucous 
membrane of the olfactory tract, or from any morbid condition 
of the olfactory nerve itself. Under this latter head may be em- 
braced lesions of the terminal filaments or trunk of the nerve or 
of the bulb. In the former class may be included acute rhinitis, 
hypertrophic rhinitis, fractures or deformities of the septum, nasal 
polypi, and other forms of neoplasm. Tumors of the pharynx or 
palato-pharyngeal adhesions may also give rise to anosmia. Among 
the causes of the disease which lie in a morbid condition of the nerve 
itself are atrophy of the bulb or of the trunk of the nerve, or the 
nerve may be absent. 

In addition to these, several congenital cases have been reported. 
Traumatism also plays an important part in the production of the 
symptom, or in a separation of the bulb from its branches as they 
enter the cribriform plate of the ethmoid. 

In one case reported permanent anosmia supervened upon a 
meningitis following a blow upon the occiput. 

Tumors of the brain, it would seem, are not liable to give rise to 
complete anosmia, in that their location as pressing upon both 
nerves would be somewhat unusual. There can be little doubt that 
very many cases of cerebral hemorrhage or neoplasm result in a de- 
struction of functional activity in the olfactory nerve on one side, and 
yet this condition is probably so masked by the more serious symp- 
toms from the central lesion that they escape notice. The main point 
of interest in this connection is that the condition always occurs 



ANOSMIA. 153 

on the left side, and is associated with aphasia and paralysis of the 
right side of the body. 

Those cases in which the affection is the result of a morbid con- 
dition of the terminal filaments of the olfactory nerve are probably 
also to be classed as neurotic. In this category are to be embraced 
those cases in which permanent anosmia results from the inhalation 
of irritating or highly offensive gases or powerful odors. Graves 
reports a case in which a man subjected himself for a period of 
several hours to the exceedingly offensive and irritating gases ema- 
nating from a cesspool. A permanent loss of smell followed. In a 
case reported by Strieker the same accident happened to an entomolo- 
gist from working several hours a day in an atmosphere surcharged 
with ether, which he used in the preparation of his specimens. It is 
a noticeable fact, in these cases, that the anosmia occurred only after 
the terminal filaments of the nerve had been subjected to the irritat- 
ing action of these agents for a prolonged period of time, and its 
prolonged action must undoubtedly give rise to some definite morbid 
change. 

Symptomatology. — The close relation between the sense of smell 
and the sense of taste has already been fully discussed in connection 
with the physiology of olfaction. A loss of the sense of smell is al- 
ways accompanied by a deterioration of the sense of taste, and it is 
through this latter deficiency that anosmia really is recognized, in 
the majority, if not in all instances. There seems to be a connection 
between the olfactory properties of the upper nasal passages and 
general sensation, although Magendie entertained the view that olfac- 
tion was dependent upon the branches of the fifth pair, a view which 
Bernard supports by reporting a case in which the disagreeable 
odors of an outhouse were complained of by a patient, in whom the 
cribriform plate, together with the olfactory nerves, were found absent 
on post-mortem examination. This may have been a case of paros- 
mia, similar to that of Berard's, or more probably, as Althaus sug- 
gests, the disagreeable odors were largely made up of ammoniacal 
effluvia of the fetid hydrogens, which could easily be appreciated by 
the general sensation of the mucous membrane. From a clinical point 
of view, however, the two properties are distinct, and in no way 
interdependent, for the anosmia may be complete while the general 
sensation is in no degree impaired. In the majority of instances, 
however, the condition is not one of complete anosmia, but rather a 
more or less notable impairment of the function. Especially is this 
true of those cases in which the condition is due to an obstructive 
lesion in the nose, which prevents the entrance of odorous particles, 
as in nasal polypi and other tumors, acute rhinitis, hay fever, etc., the 



154 DISEASES OF THE NASAL PASSAGES. 

extent of the anosmia bearing a close relation to the patency of the 
cavity. When, however, the affection is due to a nerve lesion, the 
anosmia is usually complete, although it is noticeable in this form 
of the disease that, in many cases, the complete loss of function is 
preceded by certain disturbances, such as hyperosmia or parosmia. 
Thus, in a case reported by Lockeman, the primary stage of the 
affection was marked by the appreciation of disgusting odors, while 
Althaus has observed a case in which the odor of phosphorus was a 
source of great annoyance to a patient who subsequently developed 
complete anosmia. 

Prognosis. — The differential diagnosis between essential and symp- 
tomatic anosmia is a matter of some importance as regards progno- 
sis, in that, while recovery from the former is exceedingly rare, in the 
latter, we may usually give a favorable opinion, dependent upon 
our ability to remove such local obstructive lesion in the nOse as 
rhinoscopic inspection reveals. Perhaps the only cases in which a 
favorable opinion can be given in essential anosmia are those depen- 
dent on syphilis. In a case reported by Eaynaud the anosmia 
seemed to be due to malarial poisoning, in that it was intermittent, 
recurring every day at five o'clock; moreover it was entirely cured by 
the administration of quinine. A nice question arises here, as to how 
long the olfactory nerve will retain its integrity while its function is 
affected by an obstructive lesion of the nasal cavity. It is an almost 
universal rule in the economy, applying alike to gland structures, 
muscles, and probably to nerves, that when their function is ablated 
they show a tendency at least to degenerative changes of an atrophic 
character. Hence, if the function of the olfactory nerve is suspended 
by some lesion of the nose which absolutely prevents the approach 
of odorous particles, this tendency manifests itself, and if the lesion 
remains for a sufficient period of time the nerve will have undergone 
such atrophy as that its integrity cannot be restored by the removal 
of the obstruction. No definite period can be stated during which 
the nerve may retain its functional activity, and it must vary in differ- 
ent individuals. It is not to be understood that the prognosis is un- 
favorable in cases of anosmia due either to peripheral or to brain 
lesions. 

Pathology. — It is impossible to describe any pathological lesion 
as belonging essentially to anosmia, in that the disease is a symptom 
of a variety of diseases rather than a disease itself. Thus, it may 
be dependent upon a tumor of the brain, pressing upon or involving 
the olfactory centre in or near Broca's convolution; or involving or 
perhaps pressing upon the nerves in their continuity; or upon the 
bulbs themselves. The only special interest which attaches to this 



ANOSMIA. 155 

branch of the subject, however, is in connection with the changes 
which may occur in the olfactory region. I know of no observations 
bearing on this subject, and yet it seems clear that, in many cases, 
we must concede that the diseased condition of the brain itself is 
responsible for the loss of the sense of smell. Aside from those con- 
ditions in which the approach of odorous particles to the terminal 
filaments of the olfactory nerve is prevented, this condition probably 
consists of some atrophic change occurring in the terminal filaments 
of the nerve, due either to the pressure of local inflammatory depos- 
its or to deficiency of circulation. Or, again, it may be connected 
with the degenerative changes which occur in old age, as has been 
found by Prevost. In more frequent instances, however, we must 
look for local inflammatory changes as the source of the condition. 
Thus, in an ordinary acute rhinitis we may have anosmia persisting 
for many days after the inflammatory process undergoes resolution; 
while in hay fever, in which the local inflammatory action persists 
for a still longer period of time, there may result an anosmia of even 
months' duration. The same thing also occurs in croupous and 
diphtheritic rhinitis, especially in the latter, in which the symptom 
is the result of local changes rather than of blood poisoning. 

Diagnosis. — The essential importance of the diagnosis consists in 
the determination as to whether the symptom be due to a local con- 
dition of the nasal chambers or to a diseased condition of the nerve ; 
in other words, whether we have to deal with an essential or symp- 
tomatic anosmia. This can only be determined by a careful examina- 
tion of the nasal cavity, and by the elimination of any possible local 
cause there. This, taken in connection with the history of the case 
and the concomitant symptoms, ordinarily will suffice to establish, 
with a considerable degree of certainty, the existence or non-existence 
of any central disease. 

The simple test for olfaction consists in the use of odorous sub- 
stances. In the selection of these, however, one should always make 
use of a substance which is recognized purely by its odorous qualities, 
the most delicate test, of course, being the fragrant odors, whereas 
the disagreeable odors are often deceptive, in that what is unpleasant 
often is not necessarily a genuine odor. If it is desired to accurately 
and determinately ascertain the condition of the olfactory nerve, it 
will be necessary to resort to the use of the galvanic current, Althaus 
having shown that this nerve, when healthy, affords a direct response 
to the electrical stimulus. A current from a thirty-five-cell battery, be- 
ing passed as nearly as possible through the course of the nerve, gives 
rise, according to the integrity of the nerve, to a well-marked subjec- 
tive odor of phosphorus. Unfortunately, the application of this test 



156 DISEASES OF THE NASAL PASSAGES. 

may be exceedingly limited, in that, except in rare instances, in which 
there is paralysis of the fifth pair of nerves, a current of this strength 
will be too painful for endurance. The existence of a unilateral 
essential anosmia, although not easily recognized, can be determined 
by delicate tests, and ordinarily should be regarded as evidence of 
brain lesion. A determination of the loss of smell, on one side alone, 
would require, of course, a very careful and complete closure of the 
opposite cavity, both before and behind. 

Teeatment. — Clinical observation has failed, as yet, to afford us 
any very notable suggestions for the successful treatment of an essen- 
tial anosmia. Our interest in this connection mainly centres on those 
cases in which this function is to a greater or less degree enfeebled, as 
the result of some obstructive lesion in the nasal cavity. In the 
larger number of instances the indications for treatment are nothing 
further than the removal of the organic lesion in the nose. In certain 
instances, however, in which after this has been successfully accom- 
plished the sense of smell is found still notably impaired, it becomes 
necessary to resort to measures for its restoration. For this purpose 
we may use in a routine way, perhaps, preparations of strychnine, 
arsenic, phosphorus, or any of the ordinary remedies which are sup- 
posed to possess specific properties in restoring tone to the nerves. 
I confess that I have never seen any directly recognizable good 
results from the administration of any of these drugs. It should be 
borne in mind that the alkaloids are absorbed by the nose with more 
readiness even than by the stomach, and that the full physiological 
effect of the drug is thus obtained almost as rapidly as by means of 
a hypodermatic injection. 

Our most reliable measure, however, will be the use of the galvanic 
current, commencing with daily applications of a weak current, and 
increasing the strength according to tolerance. In some cases, fara- 
dization will give even better results than the continued current. I 
think in many cases, in which the nerve has become enfeebled by long- 
continued disuse, we may stimulate it into functional activity by 
forcing it, as it were, to fulfil its normal duties. This can be 
accomplished by using not irritating but agreeable odors, of as 
powerful a kind as are easily obtainable, and frequently changing 
them. The choice of odors will be such as the patients' fancy may 
dictate, but these should be frequently changed, a half-dozen different 
ones being used in the course of the same day, and applied fre- 
quently, first to one nostril and then to the other. In this way, we 
may obtain even bettej results than by the use of electricity, or the 
internal administration of strychnine or the other nervines. 



CHAPTER XVIIL 

DEFORMITIES OF THE NASAL SEPTUM. 

Deformities of the nasal septum, as a result of either traumatism 
or inflammatory action, are probably the most frequent of all the 
exciting causes of catarrhal inflammation in the nasal mucous mem- 
brane. And it is of great importance that we should thoroughly 
appreciate, not only how they develop, but also their action upon the 
lining membrane of the nasal cavities, as well as their influence upon 
its respiratory functions. 

In health, we find the nasal septum presenting simply as a bony 
and cartilaginous wall, dividing the nasal passages into two symmet- 
rical cavities. It thus possesses no very important function in the 
economy. In diseased conditions, it presents certain abnormalities 
of contour, which undoubtedly have a marked influence in the 
production of ordinary catarrhal inflammation. The first to recog- 
nize a deformity of this structure was Quelmalz, who described 
septal deflections, attributing their existence to the habit of putting 
the finger into the cavity. 

Morgagni, making a more special investigation of these parts, 
attributed the deflections to excessive growth of the septum, by which 
it became too large to fit in its bony framework and was thus warped. 

Zuckerkandl, who has made perhaps the most thorough study of 
this subject, bases his statistics largely, I take it, on an examination 
of the cadaver, which I think unquestionably affords us more accurate 
data. In 370 crania, he found 123 symmetrical and 140 asymmetrical 
nasal septa. Among the latter, the septum deviated to the right in 
57 cases, to the left in 51, and was sigmoid in 32. 

A study of the living subject gives us still further information, 
Heymann going so far as to state that 90 per cent, of all cases exam- 
ined will show deformities. This would seem rather an extravagant 
statement. If we recognize only those deformities which give rise to 
morbid symptoms, certainly this percentage should be very much re- 
duced. 

A notable difference as regards race is observed by Zuckerkandl, 



158 DISEASES OF THE NASAL PASSAGES. 

in that 103 of his cases were barbarous or semi-barbarous people 
and in these only 24 were asymmetrical. This observation was con- 
firmed by Mackenzie, who, in 430 examples of symmetrical septa, 
found only 22.6 per cent, in the superior races. Harrison Allen also 
found, in 93 skulls of negroes, deformity of the septum in only 21.5 
per cent. 

Classification. — Various classifications have been made, but their 
practical value is not very obvious. In a general way we find the 
nasal septum, as the result of a fracture, presenting certain typical 
appearances which are easily recognized. Thus, we may have the 
cartilage of the septum broken in the vertical line in such a way that 
the projecting ridge presents in one passage, with a corresponding 
depression in the opposite side. More rarely we have the cartilag- 
inous septum broken in a line more or less nearly approaching the 
horizontal. These fractures occasionally involve the vomer in such a 
way that the horizontal ridge extends through both the cartilaginous 
and bony portions of the septum. In another class of cases, the 
injury results in a dislocation of the articulation between the vomer 
and the superior maxillary bone in such a way that the lower border 
of the septum is shifted, as it were, to one side, thus encroaching on 
the lumen of the nares. A deflection involving the posterior extrem- 
ity of the vomer I have never seen. Schaus, however, has found the 
deflection extending to the posterior nares, producing asymmetry in 
these openings. He bases his observation on digital examination 
rather than on rhinoscopy. It is characteristic of all these deviations 
that, in every case, an angular or a rounded projection of the septum 
into one nostril is attended with a corresponding depression on the 
opposite side. 

In addition to this, we find a large number of cases, in which there 
is present a more or less prominent deformity on one side of the sep- 
tum, which is not accompanied by this corresponding depression. 
This condition is always found along the sutural lines of the septum, 
and consists in a more or less well-developed angular prominence 
or ridge, which, projecting into the nasal passage, acts to obstruct 
normal respiration. In most instances, these ridges are confined to 
one side of the septum. In other cases, we find them occurring 
symmetrically on either side of the suture, thus constituting a con- 
dition not properly classified under deviation or deflection of the 
septum. These were first described by Langenbeck, who gave to 
them, mistakenly I think, the name exostoses, a term which is 
frequently used even at the present day. Subsequently they were 
recognized and described by Theile, Harrison Allen, John Mackenzie, 
Zuckerkandl, and others. 



DEFORMITIES OF THE NASAL SEPTUM. 159 

Etiology. — The causation of these deformities has been the subject 
of no little discussion, and various theories have been advanced to 
account for their occurrence. As regards those deviations which are 
due to fracture of the septum, of course there can be no question ; they 
are due to a direct blow upon the nose. When we come, however, to 
discuss the causes of the sigmoid flexure, or unilateral bulging of the 
septum, as also the sutural ridges, a pretty large field for discussion 
is opened up. That the septum may be crowded up by a highly 
arched palate is an idea worth consideration and was suggested by 
Trendelenburg, who first called attention to the frequent association 
of these two conditions. Jarvis has reported four cases in which this 
association occurred, all in the same family, which would seem to 
suggest that there might be an hereditary or systemic habit pre- 
existing, to account for the bony deformity. According to Schaus 
and Welcker, certain abnormal conditions of facial development de- 
pendent upon rachitis or mollities ostium are frequently associated 
with deformities of the septum. But these, after all, form but a very 
small proportion of cases which we observe and I think a larger clini- 
cal observation would lean to the view that traumatism is by far the 
most frequent direct cause of septal deformities. The clinical history 
of many of these cases affords direct evidence of this, and even in 
those cases in which the injury is not testified to I think it safe 
to say that an injury has occurred, which may have been of so 
slight a character as not to have excited especial attention at the time 
of the occurrence. An injury to the nose in childhood or infancy 
need not necessarily give rise to the immediate development of a 
notable deformity, as in fracture, but it may set up a low grade of 
morbid action, which, going on through a number of years, will finally 
develop a condition by which the normal function of the nose is seri- 
ously hampered. The point which I would particularly emphasize in 
this connection is that, in the first place, the lesion results in a slow 
process of development, and, secondly, that the catarrhal symptoms 
which ensue develop only after another long lapse of time. Zucker- 
kandl has shown us that deformities of the septum never occur under 
seven years of age, while Welcker saw none before the fourth year. 
This, however, does not controvert the views that I advance, for, as I 
say, the injury may occur before either of these ages, without result- 
ing in any notable deformity for many years later. Of course, these 
observations do not refer to fracture of the septum, which undoubtedly 
may occur at a very early age. Furthermore, these deformities, as 
the result of traumatism, although rarely, still do occur very early in 
life, for my own recorded cases show one operated upon at three 
years of age and another at five. 



160 DISEASES OF THE NASAL PASSAGES. 

That the injury may occur without the clinical history of trau- 
matism is very early shown by Robertson who, in an examination 
of two hundred and forty cases, found abnormalities of the nose in 
two hundred and seventeen, while there was a clinical history of in- 
jury in but eighty-three cases. 

That traumatism plays an important part in the causation of these 
deformities is the view adopted by Zuckerkandl, who, however, does 
not explain further the special method of their development. Miot, 
however, basing his conclusions on a microscopical examination 
made by Duret, finds that these prominences consist essentially of 
plastic infitration, thus establishing the fact that they are inflamma- 
tory in their origin, constituting true perichondritis. Bresgen, Volk- 
mann, Onodi, Gottstein, Hopmann, Heymann, and others content 
themselves with simply assigning a traumatic origin to most cases, 
which would seem to indicate that the deviation occurred at the time 
of the injury. The point on which I would lay special emphasis is 
that the deformity is primarily the result of traumatism, and second- 
arily of a slow inflammatory process which results therefrom. This 
view is still further strengthened by the investigations of Zucker- 
kandl, who has shown that, in many cases, there lies between the 
perpendicular plate of the ethmoid and the superior border of the 
vomer a narrow strip of cartilage, apparently due to incomplete ossi- 
fication of the temporary cartilages. Those spurs or ridges which 
run along the lower border of the vomer, at its junction with the su- 
perior maxillary, probably, in many cases, occur at the time of the 
original injury, although here we must undoubtedly recognize the 
fact that a chronic inflammatory process contributes much to their 
subsequent development into more prominent deformities. 

How far syphilis is involved in the causation of these deformities 
is rather a nice question. My own impression is that all syphilitic 
lesions in the nasal fossae run a somewhat rapid course, and develop 
very soon into ulceration with necrosis, although Trelat asserts that 
many cases are of syphilitic origin. Rickets has been supposed by 
some, notably by Loewy, to be the cause of septal deformities. No 
doubt deformities of the septum are frequently associated with rick- 
ets in the same manner that facial deformity is so associated. There 
is, however, no good reason for supposing this to be an exciting 
cause. With reference to the curious facial deformities noticed by 
Schaus and Welcker, in connection with deformities of the septum, 
it might be stated that Ziem has shown by a series of experiments 
that occlusion of one nostril in young animals will produce similar 
facial deformities. It is a question, therefore, whether deviations 
of the septum may not play a certain part in the causation of fa- 



DEFORMITIES OF THE NASAL SEPTUM. 161 

cial deformity, instead of being only a concomitant condition or a 
result. 

Most writers mention the fact that septal deformities may be con- 
genital. This is undoubtedly true, as the child in utero, as well as 
in the process of delivery, is not exempt from traumatism of a suffi- 
ciently violent character to do no little damage to the delicate tissues 
which form the nasal septum. 

Symptomatology. — Objectively, nasal deformities may occasion- 
ally be recognized by a deformity of the external nose ; this may show 
itself in what Welcker calls a scoliotic nose, in which the nasal bones 
are displaced in one direction, the tip being turned to the opposite 
side. In another form the whole nose is deflected bodily to one side. 
It is worthy of note that deformities of the external nose are of far 
more frequent occurrence than is generally supposed ; in any number 
of persons examined with a plumb line, the tip of the nasal organ de- 
viates as a rule from the median line of the face. 

Subjectively, the primary symptom to which these deformities 
give rise is simple nasal stenosis, with interference with normal nasal 
respiration. Secondarily, however, a series of changes is set up in 
the nasal mucous membrane, which eventually produce a chronic 
nasal catarrh. As already stated, I regard septal deformities as re- 
sponsible, in the large majority of cases, for the whole train of symp- 
toms, direct and indirect, which are embraced under the very general 
term of chronic nasal catarrh, or, to give it a more specific name, 
chronic hypertrophic rhinitis. The methods by which this develops 
have been thoroughly discussed in the chapter on hypertrophic rhi- 
nitis. If the deformity completely occludes one nostril, the function 
of the membrane in that passage is naturally abolished, and the 
membrane itself collapses, and is seen to be in an almost bloodless 
condition. Now, as Ave have shown, it is necessary for the develop- 
ment of hypertrophic changes that air should pass through the fossa. 
We therefore find it an invariable rule that the greatest extent of hy- 
pertrophy develops on that side which is most open. In other words, 
the combined calibre of the two nasal passages, in which deformity 
of the septum exists, is unequal to the purpose of the normal respi- 
ratory function. We thus find, in those deflections characterized by 
prominence on one side and concavity on the other, that the turbi- 
nated tissue on the concave side not infrequently grows into enor- 
mously enlarged masses, which fit into the concavity of the septum. 
Baumgarten and Seiler declare that these deflections are produced 
by the hypertrophy of the turbinated tissues. I am disposed to 
think that these writers have mistaken cause for effect; for, if this 
were true, in those cases in which we have notable hypertrophy of 
11 



162 DISEASES OF THE NASAL PASSAGES. 

both turbinated bodies to the extent of contact with the septum, as 
suggested by Loewy, we should naturally expect to find atrophy of 
the septum, or, as Bresgen suggests, even perforation. 

Deformity of the septum, probably more than any other single 
cause, gives rise to attacks of epistaxis, due to the fact that the irreg- 
ularities of the surface of the septum present certain prominences 
which are exposed to the ingoing current of air, laden with particles 
of dust and other impurities, whose action is something in the nature 
of the sand blast. The walls of the capillaries are denuded or injured, 
and become the source of more or less violent attacks of hemorrhage 
without apparent cause. 

A very notable symptom in nasal stenosis, and one which I regard 
as almost pathognomonic of deflection of the septum, is alternating 
stenosis of the passages. 

The voice is affected by a deformity of the septum, its timbre is 
impaired by the closure of the resonance chambers, and later the ca- 
tarrhal condition of the larynx and trachea which develops results in 
hoarseness and loss of voice. 

When the deflection in the region of the middle turbinated bone 
produces a narrowing of the middle meatus, the rarefaction of the 
inspired air acts more forcibly on the middle turbinated tissues, and 
we have developed conditions which present certain characteristics 
resembling the nasal neuroses, by which sneezing with watery dis- 
charges becomes a prominent feature of the trouble, the reason being 
that there is under these circumstances a nerve supply enriched by 
the distribution of the terminal filaments of the olfactory nerve, and 
thus a hyperaemic condition of the membrane renders it more deli- 
cately sensitive. It is in these cases, moreover, that we not infre- 
quently meet with hay fever, asthma, and the other reflex neuroses, 
complicating intranasal disease. 

The various ear troubles already discussed as dependent upon hy- 
pertrophic rhinitis may equally well arise from septal deformities, 
but in the latter we not infrequently find ear symptoms developing, 
even before the catarrhal inflammation has progressed to any serious 
extent. This point I regard as one of no small importance, for, in 
a number of cases which have come under my own observation, I 
have seen marked impairment of hearing completely relieved by the 
removal of a septal obstruction in the nasal passages. This would 
seem also to substantiate the opinion already expressed, that catar- 
rhal disease of the middle ear is not necessarily due to an extension 
of the inflammatory action. 

Diagnosis. — Eecognition of these deformities is based entirely on 
examination anteriorly, posterior rhinoscopy giving us absolutely no 



DEFORMITIES OF THE NASAL SEPTUM. 163 

information. I fully concur with Mackenzie that these deformities 
never extend to the posterior nares. An examination should be made 
with a good light, cocaine having first been applied to effectually 
contract the mucous membrane and open up the passage for thorough 
inspection. Care should be taken in making this examination to tilt 
the tip of the nose thoroughly to one side, so as to bring the plane 
of the normal septum into as nearly a direct right line with the ob- 
server as possible. Seiler has devised a septometer for measuring 
the thickness of the septum at various points, which may be of ser- 
vice, although much the same end may be accomplished by placing a 
speculum in each nostril, and, while throwing the strongest light into 
one, observing the translucency of the tissue through the other. The 
shadows thus formed, and the opacities or semi-opacities thus dis- 
played, often afford information which may be of value. The probe 
affords us a means of testing the character of the prominences which 
may exist, whether they are bony or cartilaginous or glandular, the 
vascular prominences being eliminated by the use of cocaine. 

Zuckerkandl has described a somewhat rounded mass of glands, 
first alluded to by Morgagni, which is found in a normal condition 
in a line about opposite the middle turbinated bone, especially at its 
anterior extremity and about the lower margin of the olfactory region. 
Creswell Baber describes this prominence as the tuberculum septi. 
It consists essentially of a mass of muciparous glands, soft to the 
touch, which need not lead to error in diagnosis. It would seem that 
the diagnosis of deformity of the septum would present few difficul- 
ties, and yet I have frequently had sent me patients with the diag- 
nosis of nasal polypus, in whom the red mass or face of the project- 
ing portion of the deflected septum occluding the nostril gave rise to 
this error. It need only be borne in mind that a polypus or fibroma 
is more or less freely movable on the impact of the probe, and soft 
to the touch, while the deflected septum is rigid and immovable. The 
same may be said of abscess or angioma of the septum. 

Prognosis. — Those cases which have not led to the development of 
complicating disorders, such as catarrhal inflammation of the upper 
air passages, ear disease, etc., of course, demand only a restoration 
of the normal respiratory freedom for entire relief to symptoms. In 
other cases in which, as the result of multiple fracture, the septum is 
crumbled, as it were, into a shapeless affair, complete restoration 
cannot be promised. When ear disease has set in, without the inter- 
position of a catarrhal rhinitis, the results of treatment are as a rule 
most gratifying. When the symptoms developed are merely those 
of catarrhal inflammation of the upper air passages, the successful 
operation on the nasal septvim goes far toward giving relief to the ca- 



164 DISEASES OF THE NASAL PASSAGES. 

tarrlial symptoms, and yet, as a rule, more or less subsequent treat- 
ment will be demanded for the relief of the condition. In hay fever 
and asthma the course is so far complicated by other elements as to 
render our prognosis exceedingly uncertain, and yet when these 
neuroses exist in connection with a deformity of the septum it is ex- 
tremely doubtful if any relief can be afforded until the operation has 
been successfully done, and perhaps no single measure in these dis- 
eases gives more satisfactory results. 

Treatment. — The essential feature of these deformities which 
demands correction is the stenosis, as from this arise all the sequelae 
and complications which accompany them. When the deformity 
has occurred as the result of a fracture, this may be attempted, either 
by removing the projecting portion of the deviation or by restoring 
the fragments to their normal plane. Ingals would restore the sep- 
tum in this way : After dissecting up the mucous membrane, he ex- 
cises a V-shaped piece from the deflected cartilage, and subsequently 
brings the parts together by sutures, thus recognizing the redun- 
dancy of tissue which is usually present in these cases, while Hey- 
mann removes the projecting portion by means of an ordinary car- 
penter's chisel, a method also adopted by Seiler. Demarquay still 
further complicates the operation by opening the cavity by an in- 
cision along the ridge of the nose, in the median line, for the purpose 
of gaining free access to the parts, after which he dissects the mucous 
membrane from the prominences, which he removes with a knife, and 
then unites the membrane over the part by sutures, subsequently 
closing his external wound in the same manner. A somewhat similar 
operation was done by A. C. Post, of New York, as quoted by Kob- 
inson. He opened the nose externally by Dieffenbach's operation, 
by an incision along the alar fissure, while Kichet, as quoted by Miot, 
opens the nasal cavity by separating the columna from the lip and 
also from the lower border of the septum, which is thus thoroughly 
exposed, enabling him to remove the projection. It need scarcely be 
added that an operation which involves incision of the facial integu- 
ment is rarely, if ever, justified for the relief of these deformities. 
Linhart, going further, deems it necessary to dissect up the mucous 
membrane on both sides of a deflected cartilage before removing the 
projecting portion. 

An instrument which was based on a thorough recognition of 
clinical indications was the punch devised by Blandin, shown in Fig. 
33, which consisted simply of a modification of the ordinary shoe- 
punch, by the use of which he was enabled to remove one or more 
small discs of the projecting portions of cartilage. Blandin' s idea 
was simply to ablate the projecting portion of the deflected septum, 



DEFORMITIES OF THE NASAL SEPTUM. 165 

recognizing the fact that the perforation did not necessarily consti- 
tute a morbid lesion. 

The punch is easy of manipulation, and in many cases in which 
the deflection represents an angular prominence accomplishes the pur- 




Fig. 33 .— Blandin's Septal Punch. 

pose of removing the stenosis in a fairly satisfactory manner. Steele 
has devised a punch (see Fig. 34) in which the cutting blades radiate 
from a centre, and when brought together produce a series of trian- 
gular flaps, which will allow of the deflected portion being brought 
down to the normal plane. John Mackenzie gives priority in this 
device to Dr. James Bolton, of Richmond, who published a case of 
deflected septum, which he operated upon by producing these stellate 
incisions by means of an instrument resembling a buttonhole-scis- 
sors, a better instrument, it seems to me, than Steele's punch; as re- 




Fig. 34.— Steele's Septal Punch. 

gards priority, the principle was first suggested by Chassaignac, who 
made use of the bistoury, which to me seems a more rational method 
than either the punch or the scissors, in that its movements can be 
directed in a far more intelligent manner. The operation which came 
most largely into vogue after its publication was that of Adams, who 
advised that the septum should be seized with a forceps, shown in 
Fig. 35, and crushed, as it were, or refractured, in such a manner 
that it could be restored to its normal plane, after which a clamp (see 
Fig. 36) was to be worn for a period of three days, followed by the 



166 



DISEASES OF THE NASAL PASSAGES. 



use of a pair of ivory plugs (Fig. 37) , which were to be worn during 
the day and removed at night, until firm union had taken place. 

Jurasz has modified this instrument by combining forceps and 
clamps in a single instrument in such a manner that, after crushing 
the septum, the handles are removed, leaving the clamps in position 
to hold the fragments in a straight line. 

When there is considerable distortion of the external nose, due 
to a bending of its cartilaginous portion, I think Adams' operation is 




Fig. 35.— Adams 1 Forceps for Refracturing a Deflected Septum. 

often indicated as serving to remedy the facial deformity, although I 
think it is not usually successful in removing the stenosis, for it must 
be remembered that, when we have fracture of the septum, there is 
invariably a considerable degree of thickening at the point of the 
original fracture, which renders refracturing in this line almost im- 
possible. Moreover, the operation is an exceedingly painful one, 
and the subsequent treatment in wearing clamps and plugs subjects 
the patient to a period of great discomfort and even suffering. 
When the facial deformity involves a deflection or distortion of the 



Fig. 





Adams' Nasal Clamp. 



Fig. 37.— Adams' Nasal Plugs. 



nasal bones Adams' operation is inadequate. I think the prominent 
indication, both in deflections and deformities, is the removal of the 
projecting portion and the restoration of the septum to a plane ap- 
proaching the normal as nearly as possible. In most of these cases, 
however, we encounter bone as well as cartilage ; a knife is utterly 
inadequate to thoroughly remove the obstruction. The scissors, 
also, I think, fail in most cases for the same reason. Furthermore, 
I deem it of the greatest importance, in removing these obstructions, 
that a thoroughly smooth surface should be left, for when a jagged, 
uneven surface remains the result is unsatisfactory, and the period 



DEFORMITIES OF THE NASAL SEPTUM. 



167 



of healing occupies an unnecessarily long time. The use of various 
forms of burrs, such as are shown in Fig. 38, operated by an ordi- 
nary dental engine, or the electro-motor, is advocated by Seiler and 
others, while Holbrook Curtis has devised a series of small trephines 



©Iff I I 



X W V U T 5 

Fig. 38.— Various Forms of Burrs for the Removal 

of Septal Deformities. 



Fig. 39.— Curtis 1 Nasal 
Trephines. 



(shown in Fig. 39), which work by an electro-motor, whose use he 
advocates for the removal of deformities of the septum. The objec- 
tion, I think, lies against these devices that they fail to leave a 
smooth, unbroken surface, which is a matter of no small importance. 

For those cases which present a horizontal ridge projecting into 
the cavity from the lower portion of the septum, the saw would natur- 
ally suggest itself as an efficient instrument, as giving a clean-cut sur- 
face and going readily through both bone and cartilage. Some years 
since, Woakes made use of this device, recognizing its value, and sub- 
sequently Seiler recommended the use of a metacarpal saw for remov- 
ing the bony projections or "exostoses." 

The essential features of such a saw are a thin blade and fine 
teeth, that it shall take hold readily of the tissue. 

The instruments above noted failing in my hands, I resorted to 
various devices for securing a proper model, till finally I had one 
constructed as follows : the blade as thin as possible, consistent with 
strength, one-eighth of an inch wide, five inches long, with a cutting 
edge of three inches, with thirty teeth to the inch, each tooth an exact 
equilateral triangle, with no cross-cut and no set to the teeth, the 
handle being three inches long, of sufficient size to be easily grasped 
by the hand, and attached to the blade at an angle of forty -five de- 
grees, in order that the hand should in no way obstruct the view 



168 



DISEASES OF THE NASAL PASSAGES. 



while operating. These saws were constructed in two forms, one 
with the cutting edge upward and the other with the cutting edge 
downward. This instrument (shown in Fig. 40) simply removes the 
presenting portion of deformities and deflections of the septum, the 

end in view being to cut as nearly 
as possible in the plane of the nor- 
mal septum. In other words, to 
saw out a new septum, as it were, 
as one would saw a board from a 
log, removing those deformities 
which may be found in either fossa. 
When this instrument was first made public I 
reported a series of one hundred and sixty-six 
operations. Since that time I have made almost 
daily use of it, and regard it as by far the best 
device we possess for the removal of these ob- 
structions. The mode of operation is as follows : 

First, with a Delano atomizer a twenty-per-cent. 
solution of cocaine is sprayed into the nostril, both on 
the obstructed and on the open side. At the end of two 
minutes a probe, wrapped with cotton, is dipped into 
the same solution and swept over the projecting por- 
tion of the septum, the membrane being by this time so 
nearly anaesthetized as to tolerate a thorough probing. 

!The cotton pellet is used to bring the cocaine in more 
\ 11 thorough contact with the septum, and also for a more 
thorough exploration of the extent and character of the 
deviation. At the end of six minutes the parts are 
thoroughly anaesthetized. The saw is now introduced 
and fixed in such a position that, in cutting, the whole 
of the projecting portion will be removed, the object 
being kept in view always to reduce the septum as far 
as possible to its normal outlines. In other words, it 
is to be sawed down, as we saw a board out of a log. 
After the instrument has entered, the sawing is done 
with as rapid a motion as it is possible to give the hand, 
care being taken to make a straight cut without bending 
the instrument. In this way the saw is carried di- 
rectly down through both bone and cartilage until it 
emerges at the lower edge. Occasionally I have used the reverse ma- 
nipulation, and sawed from below upward, when the deflection was 
of such a character as to interfere with entering my instrument well 
above the point where the projection bent from the meridian line. 




Fig. 40. —The 
Author's Na- 
sal Saw. 



DEFORMITIES OF THE NASAL SEPTUM. 169 

After cutting, the piece is generally easily removed by the forceps, 
or, if not thoroughly cut through, it can be removed by slipping the 
loop of the snare over it. The bleeding is profuse for two or three 
minutes, but in no case have I had any serious annoyance from 
hemorrhage. In two instances, I think, I have been compelled to 
plug, but in only two. Hemorrhage is arrested by clot, and I sim- 
ply direct my patient not to expel the clot for three hours, when I 
think all danger of hemorrhage has ceased. 

In regard to the operation, in only a single case have I cut 
through the septum, which illustrates the fact of its marked thickness 
at the point of fracture, and, furthermore, explains why Adams' 
operation for straightening is so often unsuccessful. 

Objection has been made to these operations that they result in 
ulceration. Now I wish to say, in as positive a manner as possible, 
that in no case have I had any such result. The subsequent treat- 
ment is nothing. The healing process requires no attention. The 
parts heal up kindly, and, as a rule, with no unpleasant symptoms 
during the process. It has been charged that bad cicatrices result. 
Again I say that I have seen no such result in any case. The mucous 
membrane reforms over the cut surface, and at the end of two months 
it would be difficult to recognize the fact that any cutting had been 
done. Too much importance cannot be laid on the necessity of a 
perfectly straight, smooth-cut surface. In one or two instances in 
operating I bent my saw, which is exceedingly flexible, in such a 
way as to make a hollow cut, sawing in a curve, as it were, leaving a 
depression on the surface of the septum. Whenever I have made 
such a mistake there has been exceedingly great annoyance from 
delayed healing, owing to the fact that mucus and bloody pus 
accumulated in the depression and formed crusts, and thus markedly 
interfered with the healing process. And herein, it seems to me, lies 
an objection to the rougher operation of the gouge and the forceps in 
removing these obstructions, as leaving an irregular surface for the 
lodgment of mucus and secretions. This, however, does not form 
ulceration. We meet with no ulcerations in the nasal cavity, ex- 
cept as the result of syphilis or some blood-poisoning. Delayed 
healing may occur, but not ulceration, after the operation; and 
delayed healing, I am positive, can only be the result of unskilful 
operating. 

I will only add, with regard to the operation, that it should always 
be done, if possible, with the use of sunlight or some equally power- 
ful illuminator, as it is of the utmost importance that the movement 
of the saw should be kept under as close ocular inspection as possible, 
in order that the line of cutting shall not deviate from that of the 




170 DISEASES OF THE NASAL PASSAGES. 

plane of the normal septum, and this can be secured only by the 
aid of thorough and powerful illumination. 



Dislocation of the Columnar Cartilage. 

In addition to the deformities of the septum already described, 
two cases have come under my observation in which the deformity 
was so peculiar that they are worthy of being reported. 

We find lying immediately below the cartilage of the nasal septum, 
and parallel with its lower border, a small oblong plate of cartilage, 

not usually mentioned in our text- 
books on anatomy, the purpose of 
which seems to be to act as a sup- 
port for the integument of the co- 
lumna. This may be designated as 
the columnar cartilage. 

The first case was that of a gentle- 
man who reported that for two years 
he had noticed something growing 
in his right nostril. The deformity, 
slight at first, had continued to in- 
crease, until, when I saw him, there 
was a considerable degree of closure 
fig. 4i.— Dislocation of the Columnar of the nostril. The facial expression 

Cartilage of the Nose into the Right wag considerably altered by the de _ 

formity, and also by the anxiety to 
which it had given rise. On examination the columnar cartilage was 
found to be displaced laterally and at the same time tilted upward, 
in such a manner that the posterior angle projected upward into the 
nostril. It could be restored to position by pressure, but when this 
was relaxed the deformity reappeared. The appearance is well 
shown in Fig. 41. 

The second case presented no points of difference from the first, 
except that the deformity was on the left side, which would suggest 
that the cause of the affection was the pressure of the thumb in using 
the handkerchief, since the first patient was left-handed, while the 
second was right-handed. After the deformity had been once pro- 
duced, vigorous efforts at clearing the nostril by closing the other 
passage, would only increase the deformity. 

The treatment in each case consisted in dissecting out the carti- 
lage through a small incision made over it, resecting the redundant 
portion of mucous membrane, and uniting the edges with fine sutures. 
The result was satisfactory in each case. 




DEFORMITIES OF THE NASAL SEPTUM. 171 



Perforation of the Septum. 

. Perforation of the nasal septum may take place through either 
the bony or the cartilaginous portions. In the former case, it is 
probably clue, in the very large majority of instances, to an ulcerative 
and necrotic process, the result of syphilis, scrofula, or of one of the 
graver constitutional dyscrasise, although in rare instances I have 
seen it occur from traumatism, the injury having caused a commi- 
nuted fracture of the vomer, with the subsequent sloughing away of 
the small fragments, by which a permanent opening between the two 
cavities was established. 

Perforation of the cartilaginous portion of the septum, on the 
other hand, is in most instances due to purely local causes, although 
this region, of course, is not exempt from the invasion of syphilis 
and other systemic dyscrasiae. The most common cause of this 
form of perforation is to be found in the existence of a projection of 
the cartilage into one or the other passage, whereby its prominent 
portion becomes subjected to the current of inspired air, laden as it 
is with dust and other impurities, whereby a process of erosion is 
established, under which the cartilage is gradually worn away until 
an opening occurs. This is a purely local process and involves no 
suspicion of a systemic taint. The existence of the erosion is attended 
with an annoying crust formation over its site, causing a frequent 
picking at the nose, by which the process of erosion is much hastened. 

This process, as we see, is really a conservative effort on the part 
of nature to relieve the patient of an obstructive lesion in the nose, and 
one, moreover, which I have frequently seen attended with signal 
success, since the removal of the obstruction seems to be the primary 
effect of the process, while the establishment of a perforation is to an 
extent adventitious. I cannot agree with Zuckerkandl in the view that 
these cartilaginous perforations are due, in the large majority of 
instances, to an ulcerative or inflammatory action, for the simple 
erosion in my experience is never attended with either of these proc- 
esses. 

The frequency of these perforations is well shown by Zuckerkandl, 
who in one hundred and fifty autopsies found eight cases. As will 
be inferred from what has been said, I am disposed to think that the 
clinical significance of openings through the septal cartilage is com- 
paratively trivial. They cause no inconvenience and indicate the 
existence of nothing other than a simple local process of erosion. 
Nor do they give rise to any symptoms, except in those rare instances 
in which the opening occurs in a septum which is bent somewhat 



172 DISEASES OF THE NASAL PASSAGES. 

diagonally across the passage, whereby the respiratory current of air 
gives rise to a whistling sound, on its entrance and exit ; while the 
erosion exists, hemorrhage is liable to occur, but this is rarely serious 
in character. The clinical significance of openings through the bony 
portion has already been sufficiently indicated. 

The erosion, however, soon heals up, leaving a smooth, rounded 
border to the opening, which is easily recognized on inspection 
through the anterior nares. There are no special indications for 
treatment. 

Abscess of the Septum. 

The spontaneous development of an abscess in the septal cartilage 
does not, in my experience, occur. As the result of traumatism, 
however, it is a not infrequent accident, and moreover one which, 
while not involving serious danger to life, is exceedingly liable to 
involve the whole of the anterior cartilage in the destructive process, 
thereby robbing the nose of its natural support, and resulting in a 
deformity which becomes a source of mortification and distress dur- 
ing life, since the tip of the nose necessarily sinks down between the 
nasal bones with notable loss of normal shape and contour. The ab- 
scess is more liable to follow upon a slight blow than a severe one, 
although it may occur in connection with a fracture. It may also 
follow the application of chemical or actual caustics. 

It develops rather insidiously, without any notable symptoms, or 
there may be a sense of soreness in the part with tenderness on pres- 
sure. As the pus sac forms it bulges into each naris in such a way 
as to cause more or less stenosis, and the subjective symptoms are 
those merely of a slight cold. 

The morbid process confines itself to the cartilage alone, and the 
mucous membrane is rendered but slightly turgescent. 

The diagnosis at times is somewhat obscure, the only morbid 
condition presenting being the soft, rounded, bulging mass, low down 
in each naris, which, being easily indented by the probe, should im- 
mediately suggest the existence of pus. This is verified by the use 
of the knife, which should always be promptly resorted to when there 
is any suspicion of pus, as even a few hours of delay may result in 
the extension of the morbid process to the anterior border of the car- 
tilage, in which case a facial deformity will surely result. When the 
abscess is opened there is no resiliency of tissue to force out its con- 
tents. Moreover, the opening is liable to close; hence a free open- 
ing should be made and the pus forced out by pressure. Occasional- 
ly it may be necessary to pass a seton through from one nostril to 



DEFORMITIES OF THE NASAL SEPTUM. 173 

the other, directing the patient to draw it back and forth several 
times daily. 

The duration of the disease is from three to six days, but on the 
first day or two the patient should be seen at least twice, or better 
still three times, since, as before stated, the disease develops insidi- 
ously, progresses rapidly, and the facial deformity may occur, or 
follow later, and in such a case, notwithstanding the exercise of the 
greatest care, the blame will fall upon the attending surgeon. 

A few cases have occurred in my own practice. In one there was 
a history of erysipelas ten years previously and a severe cold ac- 
companied by swelling of the face, which subsided in about ten days, 
and was followed by the gradual development of an external deform- 
ity, consisting in a sinking-in of the cartilaginous portion of the 
septum. In a second case the abscess was preceded by severe head- 
aches, which lasted weeks at a time ; an abscess formed on the bridge 
of the nose and was cut on the median line externally, pus being dis- 
charged in considerable amount. The symptoms returned months 
later. Upon examination the septum presented marked irregularities 
anteriorly and high up, and showed signs of a previous abscess, which 
had broken externally. A second abscess was suspected from the 
symptoms, but an incision produced only blood unaccompanied by 
pus. In the third case there was the history of a slight blow, fol- 
lowed in two days by inflammation and swelling and the formation 
of an abscess, which was opened and discharged pus. The nose then 
began to change in appearance, and I was consulted in regard to the 
deformity. I found the anterior cartilage destroyed ; there was no 
opening, but the cartilage was thickened, soft, and pliable. The 
whole anterior portion of the nose had receded. There was notable 
stenosis. 



CHAPTER XIX. 

EPISTAXIS. 

Etiology. — Bleeding from the nose, while in most cases a com- 
paratively trivial affair, in others may involve grave danger to health, 
and even to life. As a rule, it is dne to some unimportant local 
lesion, or it may arise as the result of some systemic condition. 
Epistaxis may be the result of (1) traumatism; (2) constitutional 
or systemic conditions ; (3) vicarious menstruation, and (4) local morbid 
conditions of the nose. 

Traumatic. — The most frequent injury which gives rise to an 
epistaxis is a direct blow upon the nose, causing a rupture of some 
of the blood-vessels, more frequently of the septum. Just how this 
acts it is not easy to determine. Probably, however, there is a solu- 
tion of continuity at some of the sutural junctions. Among the rarer 
injuries which cause an epistaxis may be mentioned fracture of the 
base of the skull, involving its anterior fossa. In some cases, the 
escape of blood may be entirely beneath the mucous membrane, giv- 
ing rise to a hsematoma, which may attain sufficient size, as suggested 
by Schech, to protrude from the nostril. 

Diathetic. — Among the diathetic conditions which may cause 
bleeding from the nose may be enumerated : plethora, ansemia both 
simple and pernicious, the hemorrhagic diathesis, purpura hemor- 
rhagica, organic disease of the heart, and disease of the liver and 
kidneys. It may also occur in certain acute diseases, such as typhoid 
and relapsing fevers, and, according to later writers, it occurs some- 
times in pneumonia. 

Vicarious. — Under this head we include those curious cases in 
which hemorrhage from the nose is substituted for the normal 
menstrual flow. In the same way, nasal hemorrhage at the meno- 
pause may be regarded as to a certain extent vicarious. B. Frankel 
has collected a number of cases of vicarious menstruation, which 
bring out some exceedingly interesting points. Thus, in a case of 
Kussmaul's, there was periodical nasal hemorrhage in a woman 
with total absence of the uterus, while in a case reported by Pricker 
violent hemorrhage recurred at intervals of six weeks in a girl of 
nineteen who had never menstruated, resulting finally in the death of 
the patient. Still another case was observed by Sommer, in which 



EPISTAXIS. 175 

monthly hemorrhage occurred from the nose in a woman during the 
whole period of a fifth pregnane}', while Obermeier records the 
instance of a young woman in whom regular menstruation occurred 
once at the age of fifteen, after which she had a monthly recurrence 
of nasal hemorrhage, lasting three or four days, ceasing only when 
she was pregnant. 

Joal lays special stress upon the intimate relation which he be- 
lieves to exist between the sexual apparatus and the turbinated bodies. 

Local Lesions. — Slight deformities of the septum are probably the 
cause and source of an epistaxis more, frequently than any other 
lesion met with in the nasal cavity, the apex of the projecting portion 
becoming the seat of a slight erosion. It is often stated that epis- 
taxis is met with as the result of erosions which occur in connection 
with the incrustations on the septum in atrophic rhinitis. Neither 
ulceration nor erosion ever occur, I think, in atrophic rhinitis, and, 
furthermore, the incrustations, as a rule, do not form upon the sep- 
tum. Epistaxis I regard as one of the rarest symptoms in this 
disease. The same, I think, may be said in regard to the ulcerations 
which occur in connection with syphilis and tuberculosis, the ulcer- 
ative processes in these affections rarely invading the blood-vessels. 
Neoplasms, with the exception of mucous polypi, may become the 
source of violent attatcks of epistaxis. This is especially true of 
fibroid tumors and the angio-sarcomata, and also the fibro- and myxo- 
sarcomata, though probably in a much less degree. In carcinoma 
of the nose, also, hemorrhage is a frequent symptom. Foreign 
bodies in the nasal passages may give rise to occasional mild attacks 
of epistaxis, although this is somewhat rare. 

Pathology. — The hemorrhage in these cases, in the large majority 
of instances, is undoubtedly from blood-vessels, ruptured by either 
traumatism, an erosion, or an ulcerative process. The source of 
the hemorrhage, in the very large proportion of cases, is in the septum. 

Symptomatology. — The bleeding may be somewhat trivial or in 
amount profuse. As the blood pours out it clots in the side from 
which it starts, and may gradually occlude this passage, and the 
blood, pouring over the septum, escapes from the opposite side. If 
the bleeding occurs in connection with the hemorrhagic diathesis, 
this is usually elicited by a history of former hemorrhages, and also 
may be fairly determined by the failure of the blood to form clots. 
The bleeding usually occurs from one nostril. Habitual bleeding 
from the same side would rather indicate a local lesion of that cavity, 
while hemorrhage from both sides would point probably to some 
systemic condition. Certain prodromic symptoms are occasionally 
met with, fulness in the head, vertigo, throbbing of the temples, head- 



176 DISEASES OF THE NASAL PASSAGES. 

ache, disturbance of vision, etc. These symptoms usually occur in 
individuals of plethoric habit, although certain febrile affections may 
be preceded by an attack of bleeding from the nose. Dangerous 
epistaxis may occur as the result of traumatism, or from the presence 
of tumors, and also in the hemorrhagic diathesis, disease of the 
kidneys and heart, vicarious menstruation, and the continued fevers. 
Semon, observing an epidemic of relapsing fever, met with epistaxis 
as a critical symptom in thirty per cent, of the cases, and in one 
extremely exhausted case it was the actual cause of death. 

The general symptoms which result from epistaxis depend en- 
tirely on the amount of blood lost. If excessive, faintness or com- 
plete syncope may ensue. This symptom is usually attended by a 
diminution or complete arrest of the bleeding, although it should 
always be borne in mind that, when syncope occurs, the blood may 
continue to flow into the air passages below, involving the danger of 
a new complication. 

Diagnosis. — This is simple and requires no comment. 

Treatment. — When the attack is of a mild character, it will 
ordinarily be sufficient to make an application of ice to the side of the 
nose from which the bleeding occurs, while at the same time a small 
piece may be held in the mouth, the object being to produce direct 
contraction of the blood-vessels. Indirectly, this may be accom- 
plished also by cold applied to the spine. It is undoubtedly best 
accomplished by cold applications, although Chapman's bags filled 
with water at the temperature of one hundred and five degrees have 
been used for the same purpose. The position of the patient is of 
importance, I think, the best being that suggested by Moldenhauer, 
who advises that the patient should be placed on his side, with the 
head turned forward, to allow the blood to escape from the nostril 
In every case, when feasible, an attempt should be made to locate the 
bleeding point, and in many cases this will be successful, as in the 
majority of instances the source of the hemorrhage is near the nostril, 
and can be easily brought under inspection, when a pleget of cotton 
can be inserted and pressure made by the finger on the outside of the 
nose. Mackenzie advises pressure on the outer wall of the nose by 
means of the finger inserted into the nostril, after the manner of Val- 
salva. As before stated, however, I think the rule is that the bleed- 
ing surface is some point on the septum. The same writer advises 
that pressure be made on the facial artery as it passes over the ramus 
of the inferior maxillary bone. Pressure on the septum by the finger 
inserted into the nostril may be efficacious in directly controlling the 
hemorrhage by pressure on the bleeding surface, or, as Cohen sug- 
gests, by occluding the septal artery. Keetley finds the external 



EPISTAXIS. 177 

application of hot water, of a temperature of one hundred and twenty 
to one hundred and twenty-four degrees, an efficacious measure. I 
think, we should regard the cold application as a more powerful 
agent, and our efforts should be exerted with the idea of making an 
impression of a very decided character. Mackenzie cites a case in 
which an epistaxis was arrested by plunging the body into a cold 
bath. Certain revulsive agents, for determining the blood to the 
extremities, are recommended by all writers, such as a mustard 
plaster to the calves of the legs, immersing the feet in hot water, etc. 
Virtually the same effect is accomplished by a firm ligature applied 
around all the extremities, as suggested by Patrick. 

Simpler measures failing to arrest the hemorrhage, recourse should 
be had to local applications to the nasal cavity. The simplest of 
these is the injection of cold or hot water by means of a syringe. 

Astringent applications naturally suggest themselves to any one 
endeavoring to arrest an epistaxis, and for this purpose tannin or 
alum, in powder or solution, the various iron preparations, and 
perhaps other drugs of the same class may be used. These may be 
applied by means of the syringe or spray, or carried into the cavity 
on a pledget of cotton. I have always been averse to using these 
so-called haemostatics in the nasal cavity, both on account of the 
unsatisfactory results obtained, and also from the fact that their local 
action on the healthy membrane forms an exceedingly disagreeable 
feature of the treatment. Moreover, the resulting mass of clotted 
blood, combined with the medicament used, obscures the inspection 
of the parts, and at the same time hampers further measures of 
treatment. Antipyrin is a remedy of undoubted value, and is best, 
I think, applied in the form of a powder, either insufflated or blown 
in with a tube. Of all local remedies, however, we have none whose 
action is so striking and so unvarying as that of cocaine, provided 
that we can apply it directly to the membrane, and secure its absorp- 
tion to a sufficient extent to produce its characteristic action on the 
muscular coat of the blood-vessels, by which their calibre is so 
markedly diminished. Its absolutely certain constringent action on 
the blood-vessels is best obtained by the weaker solutions, a four- 
per-cent. strength being preferable. It may be applied with pledgets 
of cotton, carried well into the cavity, one after the other, or, better 
still, in an oily emulsion as follows : 

3 Cocain. hydrochlorat. , . . . . . . . . gr. xx. 

Aquae 3 ss. 

M. ft. sol. et adde 
01. voschano, 
Vel 01. petrolati (zero) vel ol. olivi, . . . . ad § i. 

M. 

12 



178 DISEASES OF THE NASAL PASSAGES. 

This combination is easily atomized by the hand-ball atomizer 
and may be sprayed into the cavities. In this manner we secure a 
more permanent action of the cocaine. 

If the foregoing measures fail to arrest or markedly modify the 
severity of the hemorrhage, plugging should be resorted to, before 
constitutional symptoms of excessive loss of blood supervene. A 
number of mechanical devices have been suggested for plugging the 
nose, in the form of air or water bags. A much simpler and more 
efficacious method is plugging with pledgets of cotton, or the single 
large tampon. The tampon possesses the advantage of being easily 
removed after it has served its purpose, and yet I think is less effi- 
cient than pledgets of cotton packed one after the other through the 
nostril, as large a plug as can be well inserted being placed behind, 
well into the posterior nares, followed by smaller pledgets packed 
directly against it and above it until the whole cavity is filled. The 
difficult part of this procedure is the insertion of the first plug, which 
should be an inch to an inch and a half long, of the size of the fore- 
finger. This should be grasped in its whole length by a pair of slen- 
der forceps and carried through the middle meatus and well back- 
ward until near the posterior nares, when it should be packed down 
firmly on the floor of the nares with the closed blades of the forceps. 
The only difficulty about this procedure is in the subsequent removal 
of the plugs. To overcome this, it may be well to tie a string to the 
first plug only, although Schech advises that a separate string be 
tied to each plug. An excellent suggestion is made by Ingals, who 
advises the use of a strip of iodoform gauze as a tampon, for the 
decomposition which takes place in these plugs after remaining in 
situ for one or two days may give rise to unpleasant symptoms. 
The continuous tampon possesses an undoubted advantage, in that 
many cases are met with in which hemorrhage is not arrested by this 
measure ; hence the rapid removal of the plugs is of importance, in 
order to proceed to our last resort in controlling the epistaxis, viz., 
by plugging the posterior nares. The first step of this manipulation 
requires the passing of a cord through the nares, and out through the 
mouth. By far the best instrument for this purpose is a soft-rubber 
or English catheter, of small size, which will readily pass through 
the lower meatus to the pharynx, where it can be seized with the 
forceps, or thrown forward into the mouth by a hawking effort on the 
part of the patient. After the catheter is in position, a stout cord 
should be fastened to either end and drawn through the cavity. A 
pledget of cotton sufficiently large to completely fill the posterior 
nares, perhaps the size of the last phalanx of the thumb, should be 
tied firmly into the continuity of the cord, and drawn up behind the 



EPISTAXIS. 179 

palate and firmly fixed in the posterior nares. As a rule, it will be 
well to facilitate the passage of the ping to its position by the left 
forefinger inserted behind the palate, to prevent the ping from be- 
coming engaged against the velum. The remaining step consists in 
plugging the anterior nares firmly. The object of leaving the cord in 
the mouth, of course, is to enable the operator to remove the plug 
when necessary. 

The plugs should be allowed to remain in position not longer than 
forty-eight hours, when they may be with safety removed. I have 
never seen any accident follow plugging of the posterior nares, al- 
though Mackenzie cites a number of instances in which the procedure 
caused extensive gangrene of the face, tetanus, pyaemia, facial ery- 
sipelas, and in some cases resulted in death ; while Gelle reports a 
case of double purulent otitis media resulting from this procedure. 

Too much emphasis cannot be laid on the importance of searching 
for the bleeding point in every case of epistaxis before any measures 
are employed for arresting the hemorrhage. When the bleeding 
point has been located, the hemorrhage may be arrested, as a rule, 
by simple pressure, although in certain cases a local application is 
preferable in avoiding the discomfort attendant upon the insertion of 
plugs. Chiari expresses preference for the galvano-cautery in these 
cases, while Robinson condemns it, justly I think, for certainly a 
simple stick of nitrate of silver, or crystal of chromic acid, will often 
answer the purpose equally well, and is much more easy of manipu- 
lation, or, if these fail, the ordinary silver probe, heated with a spirit 
lamp to a dull heat, offers most of the advantages of the galvano- 
cautery, and, moreover, is always available. 

In addition to local measures, there are certain internal remedies, 
such as tannin, gallic acid, acetate of lead, iron, ergot, etc., which 
are regarded as possessing the property of controlling hemorrhage, 
but I think little reliance can be placed upon them. Certainly my 
own experience has failed to demonstrate their usefulness. The use 
of ergot has been somewhat warmly advocated by Mackenzie, and 
probably few of us, in severe case,s of hemorrhage, would consider 
our whole duty fulfilled without the hypodermatic administration of 
twenty minims of the fluid extract of this drug, repeated according to 
circumstances. Opium, also, in some of its forms, may well be 
given, both on account of its supposed action in contracting the 
blood-vessels and also on account of its anodyne effect, wherein I 
think lies its chief value. I should fully agree with Mackenzie in re- 
gard to the tincture of opium as the best form for its administration. 
Frankel cites instances in which periodic attacks of epistaxis, which 
he regards as having been due to malarial origin, were cured by the 



180 DISEASES OF THE NASAL PASSAGES. 

administration of quinine. Harvey also reports a somewhat similar 
case, in which the epistaxis recurred daily at 3 P.M for seven days, 
when it was finally arrested by the administration of anti-periodic 
remedies. When the loss of blood is very great, transfusion or in- 
fusion naturally suggests itself as a means of restoring the vitality of 
the patient rather than for the arrest of the hemorrhage, and yet 
Mackenzie cites a case reported by Mosler, in which the hemorrhage 
was arrested by the transfusion of blood. The infusion of a saline 
solution or of warm milk would probably answer the same purpose. 



CHAPTER XX. 

FOREIGN BODIES IN THE NASAL PASSAGES. 

Either by accident or by the curious instincts of childhood, a 
foreign body in the nose is a not infrequent condition demanding sur- 
gical interference. In the large majority of instances these bodies are 
inserted through the nostril intentionally, by mischievous children 
or hysterical females, while others make their way into the cavities 
through the posterior nares, in an obscure and curious way. Thus, 
in vomiting, a portion of the contents of the stomach is frequently 
thrown into the nasal fossse, and some parts of it may remain. Not 
long since, I removed a deciduous tooth from the nasal cavity in a 
gentleman aged thirty -seven, which had been the cause of a purulent 
catarrh for twenty -five years. In this case, the tooth, becoming 
loosened in its socket, had been swallowed at the age of twelve, and 
probably afterward thrown into the nasal cavity in the act of vomit- 
ing. A somewhat curious case is reported by Lowndes, in which a 
ring was found impacted in the posterior nares of a child of fifteen 
months. Tampons may be left in the nasal cavity by plugging. As a 
rule, these loosen themselves and come away spontaneously, although 
in one case I removed a tampon which had been inserted for the pur- 
pose of controlling an epistaxis, and which had been the source of an 
exceedingly offensive purulent discharge from one of the nasal cavi- 
ties for two years. Similar accidents are alluded to by Moldenhauer 
and Moure. ■ The objects which are inserted into the nose anteriorly 
are shoe buttons, beans, pebbles, and, in fact, any object whose size 
the nostril admits. Among rarer accidents are those in which a for- 
eign body makes its way into the nasal cavity through the external 
walls of the nose, as in the case quoted by Moldenhauer, in which a 
splinter of wood made its way through the canine fossa and was re- 
moved from the inferior meatus a month later. In the same way a 
spent bullet, fragments of iron, or other objects may make their way 
into the nasal cavity by penetrating the bones of the face. 

Symptomatology. — The immediate effect of the presence of any 
foreign body in the nose is to excite more or less profuse sero-mucous 
discharge, which is soon converted into a muco-purulent or bloody 



182 DISEASES OF THE NASAL PASSAGES. 

discharge as the result of the ulcerative process. The presence of 
the object itself causes more or less stenosis of the passage, which is 
greatly increased by the swollen condition of the mucous membrane 
which it causes, and still more by the muco-purulent secretions ac- 
cumulating in the cavity. Wherever the foreign body lodges the 
membrane becomes to a certain extent tolerant of it, and reflex symp- 
toms, such as sneezing and watery discharges, are not excited by its 
presence. Olfaction, furthermore, is not liable to be affected. Fa- 
cial neuralgia is occasionally present, and may prove an exceedingly 
distressing symptom. Erosion of the nostril and lip, as mentioned 
by Schech, is not infrequently caused by the acrid discharges from 
the nose. This is especially observable in young children. The 
same writer includes epiphora, conjunctivitis, and allied affections 
among the symptoms of foreign bodies in the nose. These I should 
regard as somewhat rare. 

Diagnosis. — The occurrence of a chronic purulent discharge from 
one nostril should always give rise to the suspicion that it is due to 
the presence of a foreign body, for in those diseases of the nose which 
are characterized by a purulent discharge the rule is almost universal 
that it is bilateral. Furthermore, the discharge caused by the pres- 
ence of a foreign body in the nose is somewhat peculiar, in that 
mixed with the pus are found small flocculent whitish masses of in- 
spissated mucus, presenting a somewhat cheesy appearance, which is 
characteristic. The ulceration in the nasal cavity is not progressive, 
and rarely I think extends through the thickness of the mucous mem- 
brane. Occasionally the pressure may produce perforation of the 
cartilaginous septum, but never a true necrosis of bone. The diag- 
nosis can only be definitely made by the use of a probe. Cocaine 
should always be applied after cleansing the cavity as thoroughly as 
possible by means of a syringe or spray, when thorough probing is 
easily tolerated. In the case of young chidren, I think it is always 
wise to adminster a few whiffs of chloroform, sufficient to produce 
primary anaesthesia, before any attempt is made at exploring the 
cavity, for thus a quiescent condition of the child is obtained, which 
will enable the operator to ascertain the presence and locality of the 
foreign body by an exceedingly brief exploration with the probe, 
without injury to the soft parts, which would be almost an impossi- 
bility with a struggling child. 

Tkeatment. — As before stated, if the patient is a child, a general 
anaesthetic should always be given in order to secure its thorough 
quiescence. If the body is small and lodged anteriorly, it will usu- 
ally be easily seized by a pair of mouse-toothed forceps. If the ob- 
ject prove too large to extricate through the nostril, it is quite feasible 



FOREIGN BODIES IN THE NASAL PASSAGES. 183 

to cut it in two by a snare or to crush it and remove it piecemeal, 
thus avoiding the necessity of forcing it through into the pharynx, 
as would otherwise be incurred, or of enlarging the nostril by the 
Rouge or Dieffenbach operation, although, if the object be too hard 
to crush with the snare, and too large to withdraw through the nos- 
tril, one of these procedures may be necessary. A simple instrument 
is the curette devised by Gross. This instrument has on its outer 
extremity a small screw for insertion into the object, an ingenious 
device, provided the screw can be inserted without forcing the body 
back into the nasal cavity. In those cases in which the object 
is lodged in the posterior nares it may be dislodged with the finger 
in the pharynx, worked in connection with the probe through the 
nose, or seized by a pair of curved forceps passed behind the palate, 
directed either by the finger or by the rhinoscopic mirror. The use 
of douches to dislodge a foreign body is not only of questionable 
efficacy but probably involves a certain amount of risk, in that the 
ordinary dangers of the douche are increased by the obstruction. 
Temain avoids the dangers of the douche by passing a catheter 
through the nose beyond the foreign body and projecting a stream of 
water against it from behind, in this manner endeavoring to force it 
out. In very young children who cannot blow the nose vigorously 
this may be done for them by the use of a Politzer's bag, blowing 
into one nostril, or by blowing into the child's mouth, although either 
of these procedures should be carried out very carefully. After all, 
however, a foreign bod}' will be usual^ extracted by means of the 
forceps or snare, and these supplemental methods need rarely be 
called into use. 



CHAPTER XXI. 

KHINOLITHS. 

When a foreign body has become impacted and remains for a lone; 
time in the nasal cavity, it becomes what we know as a rhinolitli. 
The frequency with which nasal calculi are reported in our later lit- 
erature would seem to indicate their somewhat common occurrence. 
In most of the cases given in the various reports a nucleus was 
found. In other cases no apparent nucleus was detected, yet I think 
it must have existed ; for, in the case of a large rhinolith removed by 
the author on section, it showed a small cavity which had been occu- 
pied by a kidney bean, of which scarcely any trace was left. A small 
mass of hardened mucus, as suggested by Cohen, or a blood clot, as 
suggested by Moldenhauer, may be the starting-point in one of these 
formations, of which little trace would be left. As a rule, these for- 
mations are met with singly, the only exception being a case reported 
by Axmann, in which the patient, suffering from periodic headache, 
was relieved by the spontaneous expulsion of a number of rhino- 
liths. 

Symptomatology. — A consideration of the symptoms due to the 
presence of rhinoliths involves mainly questions already discussed in 
the chapter on foreign bodies, with the additional factor that a rhino- 
lith growing within the nasal cavity attains a large development, 
which consequently involves certain additional symptoms due to the 
mere presence of the growth. These additional symptoms occur as 
the growth crowds the soft parts and even bone before it, giving rise 
at the same time to extensive ulceration and to a profuse purulent 
discharge, oftentimes of an exceedingly offensive character, which 
makes its exit through the nostril into the fauces, or through an arti- 
ficial opening in the external face or in the palate. The neuralgia 
and paralysis which accompany the development of a rhinolith are, 
of course, dependent on pressure either on the nerve trunk or peri- 
pheral filaments. 

Diagnosis. — The development of these formations is somewhat 
slow, and hence they are usually met with in adult life, though they 
may occur in childhood ; for while it is in young children that for- 



RHINOLITHS. 185 

eign bodies are most frequently met with in the nose, the conditions 
favorable to the development of a calcareous deposit do not seem to 
obtain in most instances until later in life. The diagnosis is usually 
easy, and depends mainly on investigation by means of the probe, 
cocaine being applied as thoroughly as feasible. The impact of the 
probe will reveal the location and, to an extent, the size of the rhino- 
lith, while the grating sensation will determine its character. The 
only source of error would be in the presence of necrosis of bone, or 
calcareous degeneration of the mucous membrane. These conditions, 
however, should be easily recognized, since their location is on the 
walls of the nasal cavity. 

Treatment. — The treatment of a rhinolith is essentially the treat- 
ment of any foreign body. As a rule, these formations are entirely 
too large to extract through the nostril, and hence crushing becomes 
necessary. In many instances this is easily done by an ordinary 
duck-bill forceps, or the snare ecraseur may be used, as suggested in 
connection with foreign bodies. This is applicable to soft forma- 
tions, and those in which the nucleus is large and the outer incrus- 
tation is thin. When the formation is dense and solid, more power- 
ful mechanism will be required for crushing them. For this purpose, 
any of the ordinary lithotrites designed for crushing urinary calculi 
are applicable. The crushing of a hard nasal calculus is by no 
means a trivial operation, and in most cases will require a general 
anaesthetic. Its dangers are not necessarily great, and yet Mackenzie 
states that extensive hemorrhage attended his operation, together 
with the development of facial cellulitis on the following day, 



CHAPTER XXII. 

PABASITES IN THE NASAL CAVITIES. 

Although living creatures which either make their way into tho 
nasal cavity or are developed from ova deposited there are not in the 
strict sense parasites, yet the term is used by most writers to describe 
this curious condition which, while one of the rarest events in tem- 
perate regions, is of somewhat frequent occurrence in tropical climates. 

Many cases have been reported in which the larvae of different 
dipterous insects had developed in the nasal fossae from ova depos- 
ited by the parent fly. 

Frankel states that patients suffering from ozaena are more liable 
to this invasion in temperate climates. The diptera which deposit 
their ova in the nasal cavity in temperate regions are the musca 
vomitoria, musca carnaria, and probably in certain cases the oestrus, or 
gad-fly ; in tropical climates the lucinia hominivora is the most active. 

The warm cavity of the nose provides a favorable surrounding for 
the hatching of the ova, and the larvae soon commence their work of 
destruction, invading the whole nasal cavity, and, making their way 
into the accessory sinuses and communicating passages, destroy not 
only the mucous membrane but the periosteum, and cause necrosis of 
the bone. If not arrested, they travel still farther, making their exit 
from the nose and invading the cellular tissue of the face and scalp. 

Symptomatology. — The earliest symptom due to the presence of 
maggots in the nose is a sense of formication, followed by frontal 
headache, which rapidly assumes an exceedingly distressing charac- 
ter. Frankel quotes Weber as stating that the pain in this affection 
is very great. Muco-purulent bloody discharges set in very soon, 
and increase with the progress of the destructive operations of the 
larvae. Epistaxis, oftentimes of a very serious character, may occur, 
the result of invasion of the blood-vessels. Swelling of the nose and 
face occurs, the maggots burrowing in these tissues. The swellings 
asume the character of localized abscesses. Grayson alludes to the 
possibility of confounding the affection with idiopathic erysipelas. 

In the commencement of the attack constitutional symptoms are 
not marked, though on the second or third day general shock is 
present with marked depression of the vital powers. Pus formation 
in the cellular tissue is evidenced by the occurrence of chilly sensa- 



PARASITES IN THE NASAL CAVITIES. 187 

tions or a well-developed chill. There is a rapid and feeble pulse, 
with early fever setting in, and as the disease progresses a tempera- 
ture of 102° to 103° F., or even higher. A fatal termination of the 
disease is due, probably in all cases, to the supervention of menin- 
gitis, although it would seem that the very extensive suppuration 
going on in the cellular tissue of the face and scalp might result in a 
septic condition sufficient to produce death without the occurrence of 
inflammation of the meninges. Meningitis in man}- cases is prob- 
ably due to extension of the inflammatory process by continuity of 
tissue after the invasion of the ethmoidal or sphenoidal sinuses. 

Diagnosis. — The diagnosis is comparatively simple, and one 
should be able to recognize the presence of these creatures before any 
serious damage has been done, although in most of the grave cases 
the patients do not come under observation until serious mischief 
has resulted. While the maggots confine their activity to the nasal 
passages alone, their further progress can be arrested easily. When, 
however, the accessory sinuses are invaded, or the cellular tissue, 
they are far more difficult to deal with. These cases relate entirely 
to the larvae of the diptera. The other insects which are found in the 
nasal cavity are comparatively harmless. Thus, Cochran reports a 
case in which the expulsion of about fifty screw-worms from the nose 
gave entire relief to a patient suffering with apparently a severe in- 
fluenza with high fever ; while Thiedemann has collected evidence of 
the existence in the nose of centipedes, earwigs, and larvae of the 
beacon-beetle. Leeches have been found in the nose as cited by 
Mackenzie, while lumbricoids have been ejected into this cavity in 
the act of vomiting. 

Treatment. — Chloroform diluted with an equal amount of water 
and injected into the nose has destroyed the larvae in every case in 
which it was tried when the creature had not burrowed beyond the 
reach of the drug. Mackenzie suggests that this agent might be used 
in full strength, although the patient should be anaesthetized first, as 
otherwise the application would be too painful. Inunctions of mer- 
cury have effected a cure, even after the maggots had invaded the 
cellular tissues of the face and skin and destroyed the eyes. The im- 
mediate effect of chloroform is so satisfactory that the trial of other 
remedies will rarely be justified. Grayson recommends campho- 
phenique in connection with this, as thorough disinfection of the 
cavity by douches is naturally of much importance. 

When the maggots have reached the accessory cavities these 
should be opened, if necessary and feasible. Localized abscesses on 
the face or scalp will be treated under the ordinary rules of surgical 
procedure. 



CHAPTER XXIIL 

SYPHILIS OF THE NASAL PASSAGES. 

The manifestations of syphilis in the nasal cavity are : (1) the 
primary lesion, (2) erythema or coryza, (3) the mucous patch, (4) 
the superficial ulceration, and (5) the gummy tumor leading to (6) 
deep ulceration and necrosis. 

The division of syphilitic lesions into secondary and tertiary is 
purely arbitrary ; the mucous patch and the superficial ulcer, which 
are usually regarded as secondary lesions, are frequently found in the 
later stages of the disease, while the gummata with deep ulceration 
and necrosis not infrequently occur early in the history of the 
malady. 

The Peimaey Lesion. 

Chancre of the nose is naturally one of the rarest of lesions, and 
could only occur as the result of a most untoward accident. In two 
thousand two hundred and forty-four cases observed by Bassereau, 
Clerq, Lef ort, Fournier, and Bicord, the lesion was found in the nose 
twice. In such cases the virus is conveyed by the finger nail, as in a 
case reported by Moure. The chancre in these cases is found upon 
the cartilaginous septum. It seems that when the nasal passages 
become the seat of a primary syphilitic lesion, the infective process 
assumes a somewhat more efflorescent character, and the general fe- 
brile movement which attends the onset of the disease is of a far more 
aggravated character; in Moure's case the ulcer presented a large 
granular mass, which bled easily upon touch, and which not only pro- 
duced notable stenosis, but also pressed against the ala of the nose 
to such an extent as to produce external deformity. 

Diagnosis of the Peimaky Lesion. — Our clinical knowledge of 
chancre of the nose is based on so few recorded cases that definite 
positive conclusions cannot be well drawn. The diagnosis, however, 
may be based on the gross appearance of the ulcer and the constitu- 
tional disturbance. The existence of an ulcer in the nose with a hard 
base and granular surface, bleeding easily on touch, and limited in 
extent, would suggest either tuberculosis, malignant disease, or syph- 



SYPHILIS OF THE NASAL PASSAGES. 189 

ilis. Tuberculosis occurs only as secondary to a pulmonary deposit, 
and furthermore an examination would show the existence of the 
characteristic bacillus. Malignant disease, whether carcinoma or 
sarcoma, is rarely stationary, and its development is liable to be at- 
tended with attacks of profuse epistaxis, a symptom not met with in 
chancre. The enlargement of the submaxillary glands on the side 
affected, early found in chancre, is not usually met with till late in 
the clinical history of cancer, and rarely if at all in sarcoma. Of 
course the diagnosis is completely established if the characteristic 
cutaneous eruption comes on at the end of from six weeks to three 
months. 

Syphilitic Coryza or Erythema. 

This occasionally occurs in the early stage of syphilis, but pre- 
sents no prominent features which enable us to recognize it as due 
absolutely to the specific virus. 

It occurs from three weeks to six months after the primary sore, 
and usually in connection with a roseola, although I think there can 
be no doubt that we may have a coryza in connection with the later 
development of syphilitic disease, such as mucous patches, periosti- 
tis, or the superficial ulcer. 

The Mucous Patch. 

This manifestation of syphilis shows an unmistakable tendency to 
develop in the region of muco-cutaneous junctions, such as the anus, 
the lips, or the vulva : hence we would naturally expect to find it about 
the margins of the nostrils, yet, as a fact, this is an exceedingly rare 
location for a mucous patch. Davasse and Deville, in reporting one 
hundred and eighty-six cases of this lesion occurring in females, have 
found that in only eight cases was the nasal mucous membrane in- 
vaded, while Bassereau showed that out of one hundred and thirty 
cases of this lesion observed in males, the nasal mucous membrane 
was not affected in a single case. In my own experience, I have never 
seen a nasal lesion in which I felt warranted in making the diagnosis 
of a mucous patch. If the lesion should occur, however, I take it, it 
should be recognized as presenting the same appearances as a mucous 
patch when seen in other portions of the air tract. 

The Superficial Ulcer. 

In the superficial form we meet with an ulcerative process in the 
nasal cavity, commencing apparently in the surface of the mucous 
membrane, which invades the tissue by a slow process of destruction. 
This is an exceedingly rare lesion, although undoubtedly met with. 



190 DISEASES OF THE NASAL PASSAGES. 

It occurs usually in what is called the secondary stage, namely from 
one to three years after the primary sore, and its occurrence is ex- 
plained by the breaking down of a mucous patch. I am disposed to 
think that a superficial ulcer belongs to a later stage of syphilitic 
disease, and that it is due to the breaking down of a superficial gum- 
matous deposit, for that we have an ulceration of this form, differing 
not only in its gross appearances, but in its clinical history, from 
the deep ulcer, cannot be questioned. The primary gummatous 
infiltration being superficial in character, would give rise to no notable 
symptoms which should call attention to a disease going on in the 
membrane, and, furthermore, would present no notable appearances 
on direct inspection, and our attention is therefore first directed to the 
fully developed ulcer. This form of ulcer is usually met with on the 
septum, although it is to be found on the floor of the nose or on the 
surface of the turbinated bodies. Its borders are moderately well 
defined, and the mucous membrane surrounding it is perfectly normal 
in appearance, there being no areola of redness. The edges of the 
ulcer are neither sharply cut nor depressed. Its surface, however, is 
somewhat depressed in the centre, although its periphery is usually 
flush with the surrounding membrane. Its surface is covered with a 
coating of thick, stringy, and grayish-yellow muco-pus, usually dis- 
colored by the deposit of impurities from the inspired current of air. 
If this is removed, the cleansed surface will show a grayish-pink 
color. It is slightly sensitive to the touch and bleeds easily. It 
shows no marked tendency to extend and but little destructive activity. 
Occasionally, the superficial ulcer would seem to extend deeply, and 
result in an involvement of the periosteum and an exposure of bone. 
This destruction of deeper tissues, with the resulting necrosis of bone, 
is due, as has been so clearly demonstrated by Schuster and Sanger, 
to the fact that, coincident with or even later than the superficial 
gummatous deposit, there occurs a gummatous deposit in the deep 
layer of the membrane, which results in the breaking down of the 
deeper tissues and the setting in of an ulcerative process there, after 
the superficial ulcer has fully developed. 

That the superficial ulcer is due to the gummy deposit, I think, 
is further shown by the fact that the administration of mercury has 
but feeble influence in controlling the morbid process, but that it 
yields promptly to the administration of iodide of potassium, as is 
the case with the deeper gummatous deposits. 

The Gummy Tumor. 

Under this designation ought to be included those manifestations 
of late syphilis which indicate an exceedingly active condition of the 



SYPHILIS OF THE NASAL PASSAGES. 191 

specific virus in the system. No portion of the nasal cavity is free 
from this deposit, although, in the large majority of instances, the 
deposit occurs on the septum, involving both the bony and the carti- 
laginous portions. It may also occur on the turbinated bones, or on 
the floor of the nose. The gummatous deposit shows a more or less 
well-marked tendency to rapid degeneration into an ulcerative process, 
depending somewhat on the locality of the deposit. Thus, in the 
pharynx, owing to its exposed situation, the development of the gum- 
matous deposit into an ulcerative process is so rapid that a gummy 
tumor is rarely observed in this region. In the nasal cavity, on the 
other hand, a gummy tumor is so thoroughly protected that the 
morbid process is exceedingly slow, and the existence of the tumor is 
usually recognized before ulcerative action has taken place. This 
lesion belongs essentially to what is called the tertiary stage of 
syphilis, namely, that from five to fifteen years after the primary 
lesion. 

Symptomatology of the Gummy Tumor. — When the deposit occurs 
upon the septum, it does not usually give rise to any marked pain, 
although there is usually a more or less well-marked sense of dis- 
comfort with nasal obstruction. When the deposit is upon one of the 
turbinated bones, the pain is apt to be more marked and usually 
aggravated at night. The pain is of a deep boring character, and is 
usually very distressing. Ordinarily the symptoms are sufficiently 
prominent to direct the attention of the patient to the part. 

Diagnosis. — A gummy tumor of the turbinated tissues is not easily 
recognized on gross inspection, for it is usually small and situated 
well back in the nasal cavity. In these cases, the diagnosis will be 
b.ased on the previous history of syphilis, with stenosis, deep-seated 
pain extending to the side of the face, with nocturnal exacerbations, 
together with tumefaction over one of the turbinated bones, usually 
the lower, which, on inspection, presents simply the round swollen 
aspect of hypertrophied tissue. The impact of the probe, however, 
reveals the tumefaction to be of a more solid character than turbinated 
hypertrophy. 

When upon the septum, the tumor, as before stated, attains a much 
larger size than when it occurs in other portions of the cavity, and 
presents as a large, rounded, prominent mass, projecting from the 
wall of the septum, and more or less completely occluding the nasal 
passages. In contour it is round and smooth, and is covered with a 
mucous membrane, usually of a normal tint. In other cases, we may 
find it showing evidence of deep venous injection, giving rise to a 
reddish or purplish hue. This, however, is more characteristic of the 
smaller growths. In a certain proportion of cases the lesion is upon 



192 DISEASES OF THE NASAL PASSAGES. 

both faces of the septum, although, as a rule, it is unilateral. There 
is no marked tenderness on pressure, and the growth presents a some- 
what hard, semi-elastic, cartilaginous condition. The mucous mem- 
brane covering the growth is usually unbroken. A gummatous 
condition of the septum may be confused with deflected septum and 
sarcoma. In a deflected septum the tumor is much harder to the 
touch and, furthermore, will show a corresponding concavity on the 
opposite side, which is not present in the case of a gumma. These 
cases, however, often very closely simulate a sarcoma, and in one case 
in my own experience a diagnosis of sarcoma was made ; the micro- 
scope, however, revealed the mistake. As a rule, a sarcoma presents 
a softer, more pedunculated mass, bleeding easily upon touch, and is 
somewhat movable. Moreover, its attachments are apt to be much 
higher up in the cavity. An absolute diagnosis can be made only 
with the microscope. 

Pathology. — The essential pathological lesion, which constitutes 
a gummatous deposit, is an infiltration of the mucous membrane with 
small round-cells, or inflammatory corpuscles, which invade not only 
the epithelial layer but also the mucosa proper and the deep layers 
of the membrane or periosteum, and even the bone tissue itself. The 
extent and distribution of this infiltration would seem to depend 
somewhat on the activity of the specific virus in the system. Thus, 
as we have seen, when the activity of the virus is limited, the cell 
infiltration only invades the epithelial layer of the membrane, giving 
rise to the superficial ulcer. On the other hand, when we have a 
greater activity of the specific virus in the system, the cellular infil- 
tration which we call a gummatous deposit invades the whole thick- 
ness of the mucous membrane, giving rise to more or less prominent 
tumefaction. In addition to this, the same process invades the 
vascular structures of the membrane, more especially the nutrient 
arteries. According to Sanger, we occasionally find, in the deep 
layers of the membrane, in addition to the small-round-cell infiltra- 
tion, a certain number of spindle cells, deposited in or near the 
periosteal layer. Sanger further states that, as the result of the 
oblitration of the arteries, we have a damming back of the blood, 
which may give rise to a hyperaemic condition of the tissues beyond, 
and that this is followed by localized extravasations of blood, and, as 
an occasional ultimate result, small cyst formations. 

Course and Duration. — A gummy tumor in the nasal passages 
runs a somewhat chronic course. This is due, as we have said, largely 
to its location. It develops somewhat rapidly, attaining its full 
growth in probably a very few days, after which it may remain 
quiescent for weeks and even months. In one case which came under 



SYPHILIS OF THE NASAL PASSAGES. 193 

my own observation, the tumor had existed for twelve months, appar- 
ently without great change, giving rise merely to the ordinary 
symptoms of nasal stenosis with nocturnal pains, and some occa- 
sional coryza. Probably a duration of six months is to be regarded 
as beyond the average. As the result of the peculiar anatomical 
features of the deposit the subsequent history of a gummatous deposit 
consists of a breaking down at its centre, which, gradually extending 
to the surface, results in the development of an ulcerative process. 
Endarteritis following, complete obliteration of the arteries is only 
a final result. When this, however, occurs, nutrition is arrested in 
the mass, necrosis ensues, and the whole of the tissue whose nutrition 
depended previously on the blood supply from the diseased artery 
becomes necrotic, breaks down, and sloughs away, leaving the char- 
acteristic broad crater-like ulcer which we recognize as the deep ulcer 
of syphilis. 

The Deep Ulcer of Syphilis, and Bony Necrosis. 

This lesion, arising directly from a gummy deposit, presents the 
same clinical history. It occurs usually from ten to fifteen years 
after the primary sore, although among races in whom syphilis has 
been prevalent for ages, without controlling influence of proper treat- 
ment, it seems to possess a special virulence, and hence runs a more 
rapid course. Thus, Chinese syphilis is commonly regarded as one 
of the most virulent forms of the disease ; clinical observation shows 
it to be so when contracted by Europeans, with whom it runs an 
exceedingly rapid course, the tertiary symptoms developing very 
early. This peculiar feature of syphilis, however, is excedingly rare 
among the European races, although Mauriac has observed a deep 
ulceration followed by necrosis of the nasal bones seven months after 
the primary lesion. 

Its most frequent location is fortunately upon the septum. The 
first effect of the breaking down of the gumma is to involve the whole 
thickness of the mucous membrane, and the periosteum as well, in 
the ulcerative process. After the ulcerative process becomes estab- 
lished, there is shown a tendency to extend both laterally and deeply, 
resulting in the destruction of neighboring tissues and the involve- 
ment of the bone beneath. Or, in case there has been a primary 
gummatous deposit in the bone, we have a bony necrosis as an early 
symptom. The destruction of tissue is by no means rapid, and the 
extension of the ulcer is probably due, to a large extent, to the sub- 
sequent breaking down of those portions of the membrane which have 
previously become infiltrated with the gummatous deposit. For I 
13 



194 DISEASES OF THE NASAL PASSAGES. 

think it is exceedingly doubtful if we ever have a further gummy 
deposit, after the first deposit occurs, the syphilitic explosion, as we 
may call it, expending itself when the first gummy tumor develops. 
An additional feature, which I think is characteristic of the deep 
syphilitic ulcer, is that it shows a marked hesitancy in transgressing 
anatomical boundaries. This, probably, is due to the fact above 
stated that the ulcerative process is limited by the original gummy 
deposit. Certainly these ulcers do not extend beyond the nostril to 
the skin, nor do they extend beyond the posterior nares into the 
pharynx. 

Symptomatology of the Deep Ulcer. — With the breaking down 
of the gumma, the peculiar boring pains with nocturnal exacerba- 
tions disappear, and there is a profuse sanguino-purulent discharge 
mixed with the blackened shreds of necrotic tissue. These show a 
tendency to accumulate on the face of the ulcer in large masses, which, 
drying, form crusts. These crusts are exceedingly offensive; indeed 
their odor is intolerable, especially when the disease has extended to 
the bone. This odor is present about the person of the patient at 
all times, and is in every way characteristic. With the bloody crusts 
small spiculse of bone, and later large sequestra, may be expelled, 
either through the nose or through the pharynx. As the ulcer 
extends, the crusts become much larger, and are discharged with 
difficulty, the cavity becoming blocked up with a great mass of bloody 
pus and necrotic tissue, giving forth a hideous odor until relief is 
obtained by the interference of the surgeon. 

The sensibility of the nasal cavity seems to be notably diminished 
in syphilitic disease. The sense of smell is usually abolished or 
markedly impaired. 

Deep syphilitic ulceration, unless arrested very early in its career, 
results in necrosis of the bony tissue or cartilage beneath. If it 
occurs upon the turbinated bones, the necrosis involves no external 
deformity, but confines itself simply to the destruction of such portion 
of the bone as may be involved in the original gummatous deposit. 
When the ulceration occurs upon the cartilaginous septum, necrosis 
occurs very early and runs a somewhat rapid course, usually involv- 
ing the whole of the cartilaginous portion of the septum in the 
destructive action. The result of this is that the tip of the nose is 
robbed of its support and sinks in, producing the peculiar deformity 
so easily recognized as the result of this lesion. In certain cases, 
although exceedingly rare, the destruction of the cartilaginous septum 
is attended with a destruction of the columna of the nose, thus con- 
verting the two nostrils into one single orifice over which the sunken 
tip of the nose falls. If the original gummatous deposit is circum- 



SYPHILIS OF THE NASAL PASSAGES. 195 

scribed in extent, perforation of the septum occurs without causing 
any external deformity. When the bony septum is involved the 
destruction may be limited to a portion of the septum, or complete 
destruction of the vomer may take place without any external deform- 
ity. In other cases, however, the nasal bones are also involved in the 
morbid process, probably as the result of the original deposit of 
gummatous material in the bones themselves. When they are 
destroyed the resulting external deformity is quite as noticeable as 
the one previously described ; the bridge of the nose sinks in, leaving 
the tip of the nose intact. The sinking in of the bridge is attended 
with a certain amount of atrophy of the tissues of the external nose, 
and there is left simply a rounded elevation representing the original 
bony bridge, which thus throws the unchanged nasal tip into greater 
prominence. I have never seen this form of external deformity result 
from gumma of the nasal bones alone, if such a thing ever occurs. 
The nasal processes of the superior maxillae are usually also involved 
to a certain extent in the same necrotic process which attacks the 
nasal bones. 

Diagnosis of the Deep Ulcer. — After the ulcerative process has 
commenced in a gummy tumor, the destruction of tissue goes on 
very rapidly, until the whole growth has broken down and developed 
into the characteristic deep ulcer or tertiary ulcer of syphilis, which 
now presents appearances so typical in character as to render the 
diagnosis comparatively easy, and the subjective symptoms are usually 
sufficient to establish the diagnosis beyond much question. 

The areola of the ulcer is characteristic in its exceedingly bright 
and glassy -looking red color, which extends some distance beyond its 
border. The gross appearances are quite sufficient to establish the 
diagnosis. 

It has already been shown that the deposit extends very deeply 
through the mucous membrane, and usually involves the deep layer 
or periosteum. Hence, the bone is usually found to be denuded — a 
fact which is easily established by the use of a probe, which should 
always be used both for determining the existence of denuded or ne- 
crosed bone, and, furthermore, to establish the extent of tissue which 
the ulcerative process involves. If the disease has existed for a suffi- 
cient length of time to result in the formation of a sequestrum, this 
fact is also determined by means of the probe, as the mobility of the 
mass is thus easily ascertained. The ragged tissue about the edges 
of the ulcer occasionally develops a typical myxoma ; in rare instances 
there are groups or masses of polypi, which for a time may obscure 
the diagnosis. Their removal is easily accomplished, when the dis- 
eased action beneath is readily made manifest. In addition to this, 



196 DISEASES OF THE NASAL PASSAGES. 

a certain exuberant granulation tissue is noticed in the majority of 
cases, more or less efflorescent in character, upon the ragged ulcerat- 
ing edges, and extending over the diseased surface of the ulcer. This 
presents the typical appearance of granulation tissue, except that it is 
somewhat redder, and is usually covered with the offensive secretion 
from the ulcer. It is of a somewhat yellowish color, and bleeds easily 
on being touched with a probe. 

Another appearance quite characteristic of the tertiary ulcer in 
the nose is the accumulation of a peculiar, clear-white substance, 
having much the appearance of potted cheese. This is found above 
and beyond the ulcerative process, and seems to consist of mucus 
which has been imprisoned in the narrow portion of the nasal cavity, 
and has undergone cheesy degeneration. This comes away in large 
flakes upon cleaning the ulcer. This condition is almost pathogno- 
monic of a syphilitic ulcer, as I have rarely seen it in any other form 
of diseased action on the nose. 

Coukse and Duration of the Deep Ulcer. — As before intimated, 
I am disposed to think that the deep ulcer of syphilis simply involves 
those tissues which had originally been the seat of the gummy deposit, 
and that there is no tendency to spread to the neighboring tissues. 
The disease runs an essentially chronic course, after the ulcer has 
been established, owing to the fact that the morbid process has ex- 
tended to the bone, resulting in its denudation and subsequent 
necrosis. Whether the original gummy deposit be in the bone or is 
simply confined to the mucous membrane or the periosteum, necrosis 
is the result. In the former case, however, it would involve a larger 
and perhaps more rapid ulcerative action. 

If the disease is located upon the vomer, it may result finally in 
producing simply a bony sequestrum, which causes a perforation of 
the vomer, or it may involve the whole bone and a certain portion of 
the hard palate, causing perforation and the appearance of the disease 
in the roof of the mouth. I am disposed to think that this compli- 
cation arises as the result of the original gummy deposit involving a 
small portion of the floor of the nose, or the upper surface of the 
hard palate. 

As regards the danger of external deformity resulting from syph- 
ilitic disease in the nose, this I think is clearly indicated by the 
extent of the original lesion. Thus, deformity may arise from the 
destruction of the bony or cartilaginous septum, or the nasal bones, or 
both. If the original gummy tumor has involved these, an external 
deformity is inevitable. The prognosis, then, as regards external 
deformity, depends entirely upon the location and extent of the ulcer. 
Thus, even a small ulcer involving the nasal bones would result in 



SYPHILIS OF THE NASAL PASSAGES. 197 

deformity, while a large ulcerative process located upon the posterior 
portion of the vomer involves no danger whatever of such an acci- 
dent. Again, an ulcer of considerable size, located upon the central 
portion of the cartilaginous septum, may produce a large perforation, 
leaving a mere ring of cartilage. If, however, this ring is complete 
anteriorly, an external deformity need not result. If, on the other 
hand, the disease extends to the anterior edge of the cartilaginous 
septum, a sinking-in of the tip of the nose is inevitable. Original 
syphilis of the nose, as a rule, remains a syphilis of the nose. An 
extension, for instance, through the anterior nares to the integument 
never directly occurs. The same I think can be stated in regard to 
any extension into the pharynx. As we have already seen, apparent 
extension to the oral cavity is the result of an accident, and is not really 
an extension of the disease. An interesting question, in this connec- 
tion, is the danger of septic absorption from the exposed bone, con- 
stantly bathed as it is in a purulent fluid. This is ordinarily regarded 
as constituting a condition especially favorable for the production of 
septic infection, and yet as a matter of clinical observation I think 
this complication is an exceedingly rare one. Herman Weber has 
reported a case of syphilis of the nose which establishes beyond 
question the possibility of a general septic infection having its origin 
in necrosis in the nasal cavity. Though undoubtedly cerebral symp- 
toms are present in many cases of syphilis of the nose, I quite agree 
with Schuster in his statement that they are to be regarded as re- 
flex manifestations rather than as evidence of brain lesion. 

Treatment. 

The Primary Lesion. — In dealing with a hard chancre in the nose, 
there are no indications for treatment, other than the use of simple 
lotions for keeping the parts clean. If the ulcerative process is active, 
this may be controlled by the local application of iodoform or iodol. 
If the diagnosis has been fully established by the appearance of the 
characteristic syphilitic eruption, the patient should be put on a 
course of mercurial treatment. Caustics should not be used, in that 
no good purpose is thus accomplished. 

The Coryza or Erythema. — A syphilitic coryza subsides readily 
under general medication, and as a rule requires no local treatment. 

The Mucous Patch. — The indications for the treatment of a mucous 
patch here, as elsewhere, consist in its thorough and complete de- 
struction, by means of chromic acid or some equally efficient caustic, 
applied daily until the morbid process is completely arrested. 

The Superficial Ulcer. — The essential feature of treatment in this 



198 DISEASES OF THE NASAL PASSAGES. 

form of ulceration consists in the administration of iodide of potas- 
sium, commencing with a dose of fifteen grains, three times daily, 
after meals. Its efficacy is easily tested by watching the progress of 
the ulcer. If the morbid process is not immediately brought under 
control, the dose should be increased on the third or fourth day to 
twenty grains, and if necessary at the end of a week to twenty-five 
grains, although cases are very rare in which the administration of 
doses larger than fifteen grains will be demanded in this form of 
ulcerative action, as I am disposed to think a superficial gummatous 
deposit indicates that the specific virus in the system is not specially 
active. In connection with the iodides, either the bichloride or bin- 
iodide of mercury is to be administered, in doses of one-sixteenth of a 
grain three times a day. After the ulcer is completely healed, the 
further administration of the iodides is not indicated. The mercurial 
treatment, however, of course, should be continued for from eighteen 
months to two years. 

The patient should be seen daily and the progress of the disease 
watched with care, not only to test the efficacy of the general remedies, 
but also to guard against the very possible mistake of regarding a 
deep ulcer as one of the superficial variety. The surface of the ulcer 
should be kept thoroughly clean by the use of some simple cleansing 
lotion and powdered daily with iodol or iodoform. 

The Gummy Tumor. — The early recognition of a gummy tumor is 
of special importance. Few lesions in syphilis are more directly 
amenable to internal medication than this manifestation ; under iodide 
of potassium it rapidly disappears. I do not entirely agree with 
those who advocate the use of this drug in extremely large doses. 
Certainly, in this lesion, as manifested in the nasal cavity, my own 
experience goes to show that the administration of twenty grains of 
iodide of potassium, three times daily, is quite sufficient to accom- 
plish the desired end. I do not say that all cases can be controlled by 
this amount. The administration of the remedy, however, should 
be commenced with this dose, given three times daily. If at the 
end of the second day a notable subsidence in the tumor is not 
observed, the dose should be increased to thirty or- even to forty 
grains. As a rule, however, the twenty-grain dose will prove suffi- 
cient. The amounts above given should be administered in at least a 
wineglass of water to each dose. Full doses of the iodide are to be 
continued until every vestige of the gummy deposit has disappeared, 
and continued in ten-grain doses three times daily for ten days. 
When the iodides are not tolerated on account of the excessive irrita- 
bility of the stomach, the drug should be given in a wineglass of milk. 
If this is not sufficient, it may be given for a short period by the 



SYPHILIS OF THE NASAL PASSAGES. 199 

rectum. The diet should be regulated when the iodides are not 
tolerated ; perhaps the best plan is to restrict as far as possible the 
use of vegetable food, putting the patients mainly on an albuminous 
diet and restricting the use of tea and coffee, alcohol and tobacco 
being entirely interdicted. Or, we may place the patient on a milk 
diet for a time ; the nourishment is administered in thoroughly ample 
quantities and the stomach is but slightly taxed. 

A change of climate sometimes overcomes this intolerance, but 
frequently intolerance of the iodides resists all our ingenuity. We 
may, therefore, occasionally intermit the drug and put the patient 
under a course of general tonic treatment for a week or ten days. 

Another serious obstacle occasionally met with in the administra- 
tion of the iodides is the production of iodism, which I have seen 
resulting from the administration of even small doses, giving rise to 
an intense irritation of the mucous membrane of the whole upper air 
tract as well as of the conjunctivae. This difficulty, however, is 
readily overcome in most cases by adding to each dose of the iodide 
ten grains of the bromide of potassium. 

I am disposed to think mercury has but very little effect upon a 
gummy tumor, and although there is good authority for the doctrine 
that in this stage of the disease its administration should be combined 
with that of the iodides, I am disposed to think it had best be avoided 
until the iodides have fully accomplished their purpose, when, of 
course, it should be administered after the manner to be described 
later. There is no local treatment specially indicated in the manage- 
ment of a gummy tumor. 

The Deep Dicer. — The treatment of the deep ulceration demands 
the thorough cleansing of the part with some simple carbolized wash. 
After the ulcer is thoroughly cleansed, any necrosed tissue which is 
found should be removed by means of the snare or a sharp spoon. 
After this, the ulcer should be filled, by means of the insufflator, 
with powdered iodoform or with iodol. This procedure should be 
repeated daily, until healthy action is established in the diseased tis- 
sues. At the same time, the patient should be directed to make use, 
three or four times daily, by means of the nasal douche, or by simple 
insufflation from the palm of the hand, of a cleansing lotion. 

An exceedingly nice way of using a lotion is by means of the 
hand-ball atomizer shown in Fig. 18. In this stage of the disease, 
much smaller doses are required than in the primary stage of gum- 
matous infiltration, and I think a larger dose than twenty grains of the 
iodides is rarely indicated. This should be administered until there 
is evidence that the disease is well under control, and that such 
ulcerative action as remains is due only to the existence of necrosed 



200 DISEASES OF THE NASAL PASSAGES. 

bone. There is no objection to the commencement of the adminis- 
tration of mercury in this stage of the disease in connection with the 
iodides, using either the bichloride or biniodide, in doses of one- 
sixteenth of a grain three times daily. 

If the probe reveals the existence of necrosed bone beneath the 
ulcer it should be removed, for in many cases this undoubtedly keeps 
up the diseased action. It is important, however, to distinguish be- 
tween necrosed and exposed bone, for in the latter case the probe 
often gives indications which may very closely simulate those of 
necrosis. The impact of the probe upon necrosed bone gives rise to 
a hard, dry, gritty sensation, which is notably different from that of 
merely exposed bone, where there is a slight suggestion of softness 
and moisture in connection with the gritty feeling. If the part is 
completely necrosed, and a loose sequestrum has formed, it is to be 
removed by means of a stout pair of forceps. If it is too large for 
removal, it should be broken up with a proper crushing instrument, 
or, better still, by the snare. 

If the sequestrum has not fully separated itself, I am disposed to 
think it is well to wait until this has taken place, for separation 
rapidly follows the necrotic processes. Certainly I do not approve of 
the burr and dental engine, which have been used so much of late in 
these cases. I have seen no case of necrosis of the bones of the nasal 
cavity in which a sufficiently accurate diagnosis of the size and 
locality of the sequestrum could not be made by means of the eye and 
the probe to render its removal comparatively simple and without 
injury to neighboring parts, which is so liable to occur from the use 
of the burr. 

The General or Constitutional Treatment of Syphilis. — After 
the local lesion has been satisfactorily disposed of, the further indi- 
cation, and by far the most important one, is to eliminate the syph- 
ilitic poison from the system, by a prolonged course of mercurial 
treatment, the details of which are best found in the standard works 
on the subject. 



CHAPTER XXIV. 

CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 

Syphilis in the father or mother is exceedingly liable to be followed 
by syphilis in their offspring. It is a remarkable fact that a woman 
may bear a syphilitic child who is herself immune and cannot be 
infected; she has received a sort of protective inoculation, without 
having had any actual manifestations of the disease. A syphilitic 
father may beget a healthy child ; on the other hand the child of a 
man long since considered cured may be syphilitic. The transmis- 
sive power under judicious treatment, however, rarely exceeds three 
or four years. These problems, however interesting, need not be dis- 
cussed in the present chapter. 

With the exception of the primary sore, every feature of the 
acquired disease may be seen in the congenital form. Speaking 
generally, when the child is not actually born with symptoms of the 
disease, it usually from the fourth to the eighth week, rarely later, 
begins to show them. 

The earliest manifestation of congenital syphilis in children is 
either in a coryza or in some form of cutaneous eruption. In still 
rarer cases, we have iritis, deafness, or some obscure brain symp- 
toms. I know of no statistics bearing on the frequency of the 
special lesion, although, unquestionably, in the large majority of 
cases, the first manifestation of syphilis in children occurs in the 
form of a coryza, which, manifesting itself by the ordinary symptoms 
of nasal stenosis with watery discharge, as the disease progresses 
gradually develops into a muco-purulent discharge of a somewhat 
acrid character, giving rise to irritation of the muco-cutaneous junction 
and of the upper lip, together with crust formation about the margins 
of the nostrils. The essential lesion consists of an inflammation of 
the mucous membrane lining the nose, apparently a non-specific 
rhinitis. The diagnosis must depend in part on the clinical history 
of the case and the concomitant appearances, but mainly on the 
general appearance of the child, which shows very marked evi- 
dence of malnutrition, the skin presenting a pale, somewhat earthy 
color, while the general facial expression gives to the child a 



202 DISEASES OF THE NASAL PASSAGES. 

pinched and old-man face, as it were. In connection with this, in 
the majority of cases, either concomitant with the development of the 
nasal symptoms, or soon after, there appears the ordinary eruption 
on the skin, which verifies the diagnosis. This makes its appear- 
ance usually about the anus or buttocks, and afterward spreads over 
the body. It is usually papular in character, presenting the typ- 
ical copper color. The further manifestation of the disease in the 
nose consists in the deposit of gummatous material, either in the 
superficial or deep layers of the membrane, which, breaking down 
rapidly, results in an ulcerative process. This phase of the disease 
is manifested by an increase of the pus discharge, which has now 
assumed a somewhat offensive character and is mingled with blood 
and shreds of black necrotic tissue. The secretions from the ulcer- 
ative surfaces form hard incrustations, which, drying, by a somewhat 
rapid process of accretion obtain such size that they cannot be 
expelled from the cavity, and hence form an additional source of 
irritation, in that they may give rise to reflex brain disturbances, 
which may lead to the suspicion of the existence of some form of 
brain-syphilis. 

Congenital syphilis of the nose in young children runs an exceed- 
ingly rapid course, the ulceration following rapidly on the coryza, 
which very soon leads to exposure of bone and subsequent necrosis, 
as external deformity shows itself very early in the history of the 
case, evidencing the fact that the whole of the bony septum, and 
probably some portion of the nasal bones, have been destroyed. In 
a case reported by Hawkins, nasal syphilis developed in a child six 
weeks after birth, resulting in complete destruction of the vomer, 
with sinking in of the nose four months later. We thus find the 
clinical history of the development of syphilis in children differing 
from that of adults in a very striking degree. This is not to be 
explained by the view that inherited syphilis is a more active poison 
than the acquired form of the disease, but rather by the fact that 
small children possess a comparatively slight power of resisting the 
inroads of any disease; hence, the syphilitic virus makes a very 
powerful impression from the onset upon infants, giving rise to a 
general impairment of all the nutritive powers, as evidenced by their 
general cachexia already described, this general cachexia not being 
necessarily a direct, but an indirect result of the disease. 

Diagnosis. — The diagnosis of nasal syphilis ought to be compar- 
atively easy in all cases, in the early stage, when it is characterized 
by a simple corzya. It should be remembered that the turbinated 
tissues are in a very early stage of development at birth and for some 
months later; hence an acute idiopathic rhinitis is an exceedingly 



CONGENITAL SYPHILIS OF THE NASAL PASSAGES. 203 

rare disease at this age. Furthermore, if by any chance such a dis- 
ease exists, it would run the ordinary course of a few days and 
undergo resolution, whereas in syphilis it progresses rapidly toward 
the development of a discharge, of such a decidedly purulent charac- 
ter as to eliminate the possibility of its being an acute rhinitis even 
in its late stages, wherein the discharge never obtains an absolutely 
purulent character. In a purulent rhinitis in children, in the early 
stage of atrophy, the disease never develops earlier than from three to 
four years of age, and in its earlier stages is an exceedingly mild 
affection, and not characterized by any notable stenosis, or great 
swelling of the mucous membrane. Hence in a given case of coryza, 
in the first few months of life, suspicion should always be excited of 
the existence of inherited disease. If, in addition, the child is small, 
poorly nourished, and presents the ordinary appearance of amemia, to- 
gether with an earthy tint of the skin, and an old-man look in the face, 
we have still further confirmation of this suspicion. The appearance 
of the characteristic eruption, however, renders the diagnosis com- 
plete, and this should be easily recognized from its gross appearances. 
Still later developments, as bloody pus mixed with necrotic tissue, in 
connection with the characteristic fetor which attends an ulcerative 
process in the nose, of course, leaves no possibility of mistake in diag- 
nosis. Biiumler alludes to the characteristic appearance of the external 
nose, in these cases, which consists mainly in a depression or flattening 
of the nasal bridge, together with a protrusion of the frontal sinuses. 

In addition to these objective symptoms, much light can be 
thrown on the matter of diagnosis by making close inquiry as to the 
possibility of syphilitic disease in either the father or mother. This 
clinical feature of the disease can usually be investigated very 
thoroughly, and the facts of the case established with a fair degree of 
certainty. As a matter of clinical observation, any father or mother 
who has had a primary syphilitic lesion within three years preceding 
conception is liable to transmit the disease to the offspring. 

Prognosis. — The early development of syphilis in children is to 
be regarded as an evidence of the activity of the specific virus in the 
system. Thus, in a case in which the evidences of the disease are pre- 
sented at birth the prognosis is simply bad, as those cases are rarely 
amenable to treatment — one of the most serious features of the case 
being that the nasal disorder so far interferes with nursing as to 
lead to the very early development of mal-nutrition or marasmus, and 
the children usually succumb, largely as a result of this complication. 
On the other hand, we may state it as a rule, that the later the devel- 
opment of the disease, the more favorable the prognosis, in that the 
child has had an opportunity of gaining vigor and strength to combat 



204 DISEASES OF THE NASAL PASSAGES. 

the blood poison when it manifests itself, and, furthermore, I think it 
may be stated as a rule, that the later the disease manifests itself, the 
slower its progress, hence the better the opportunity for establishing 
the diagnosis, and placing the child under proper remedial measures. 
Briefly the prognosis depends upon the time at which the disease 
develops, the extent of tissue involved, and lastly, but of most impor- 
tance, on the general condition of the child. 

Tkeatment. — The local treatment of the coryza is a matter of some 
importance, if thereby we are enabled to restore the passages to their 
normal patency, and thus allow the child to take its' nourishment in 
proper amounts from the breast. For this purpose we, perhaps, 
possess no remedy which is so efficacious as cocaine, which should be 
used in the form of a spray, in about half-per-cent solution, or, 
perhaps better still, in the form of an emulsion with some oily sub- 
stance. Astringents possess no value in this condition. The integ- 
ument about the margins of the nostrils is always exceedingly tender, 
and should therefore be protected by the local application of vaseline 
or cold cream. After the disease has progressed to the ulcerative 
stage, our efforts are directed entirely toward keeping the parts 
thoroughly cleansed and applying iodol or iodoform. The difficulty, 
of course, in cleansing the nose in an infant is that the child cannot 
blow its own nose. This is fairly well accomplished for the child, by 
fitting the nozzle of the spray apparatus into the nostril and blowing, 
the reservoir of the spray being empty ; the current of air blown into 
one nostril escapes with considerable force through the other, carry- 
ing with it such mucus or pus as may lie in the cavity. 

In any event the child should be brought as rapidly as possible 
under the influence of mercury. If administration by the mouth is not 
possible, inunctions should be used — five grains daily of the ointment 
or two to three grains of the oleate of a twenty-per-cent. strength. 
The mercurial bath may be used with advantage, eight or ten grains 
of corrosive sublimate, in four or five gallons of tepid water, into 
which the child is placed, and allowed to remain from ten to fifteen 
minutes, care being taken to exclude water from the eyes, mouth, and 
nose. If ulceration exists in the nasal cavity, or evidence of gummy 
deposit, it is well to administer small doses of iodide of potassium, 
for a limited period of time, its duration being governed by the 
toleration of the child and the impression which the remedy makes 
upon this special feature of the disease. The dose, however, should 
not be increased above two grains, given three times daily. It should 
be given in connection with the biniodide or bichloride. In addition 
to the constitutional treatment, the general condition of the patient 
should be zealously looked after. 



CHAPTER XXV. 

TUBEKCULOSIS OF THE NASAL PASSAGES. 

Tuberculous disease invades the nasal passages with greater rarity 
than any other portion of the respiratory tract. Thus Willigk, in 
four hundred and seventy-six autopsies of tuberculous cases, found 
but one case in which the nasal • membrane was involved, while 
Weichselbaum found two cases in one hundred and sixty-four autop- 
sies. The first to recognize the disease during life was Laveran, who 
reported two cases, in which advanced tuberculosis was complicated 
by a low form of sluggish ulceration upon the septum, which he con- 
sidered due to a tuberculous deposit. In one of these cases the 
diagnosis was confirmed by autopsy, while in his second case there 
was some question whether the disease was genuinely tuberculous in 
character. 

There are in all about twenty cases, on which, I think, our knowl- 
edge of the clinical history of the disease must be based. 

Etiology. — The disease occurs in connection with either pulmonary 
or general tuberculosis, exceptions to this rule being two cases of 
Kiedel's in which the diagnosis is doubtful, and a single case of 
Schaffer's in which no pulmonary disease was recognized. Hered- 
itary influence is shown to exist in a large proportion of cases of the 
disease. How far the local condition of the nasal cavity may affect 
the ulcerative process cannot be determined. 

Pathology. — A tuberculous process in the nasal mucous membrane 
manifests itself in two forms. In the one case, it develops in the 
ordinary tuberculous ulceration, very similar to that observed in other 
portions of the air tract. In other cases, it shows a tendency to hy- 
perplasia, in the form of small tumors varying in size from bird-shot to 
a pea, presenting a somewhat mammillated or raspberry -like surface, 
the growths being attached to the parts beneath by a broad base. The 
ulceration, in the majority of instances, shows itself on the septum or 
floor of the nares, while the neoplastic form, on the other hand, is 
more frequently found on the turbinated bodies, although occasionally 
found on the septum also. Examination will determine whether the 



206 DISEASES OF THE NASAL PASSAGES. 

form be neoplastic or ulcerative. A section of the growth exhibits a 
fine basment membrane of connective tissue, richly infiltrated with 
round nucleated cells (lymph cells), together with larger nucleated 
epithelial or endothelial cells, and sometimes, but not always, true 
giant cells. The normal gland structure of the membrane is more or 
less modified, the glands may appear normal, or they may be dis- 
torted by the pressure of the surrounding inflammatory products. 
The gland epithelium may degenerate, or it may simply be pushed 
off, as it were, by the infiltration of the tissues by the round cells. 
The tissue immediately about the ulcer or tumor, as the case may be, 
shows an abundant round-cell infiltration. Under the microscope 
tubercle bacilli are found, and are usually present in rather small 
numbers. 

Symptomatology. — If the disease takes on the ulcerative form, the 
prominent symptom will be the discharge of grayish mucus, more or 
less profuse, according to the extent and size of the ulceration. If the 
ulceration is on the septum, especially if near the nostril, crust for- 
mation will prove a source of annoyance to the patient. In these cases 
also, slight hemorrhage is liable to attend the dislodgment of the 
crusts. Pain is rarely present, either subjectively or as the result of 
pressure. In the neoplastic form of the disease, the prominent symp- 
tom attendant upon the presence of these small growths is obstruction 
with a moderate amount of secretion and occasional hemorrhage. 

Diagnosis. — A tuberculous ulcer, wherever it may be, presents a 
certain characteristic appearance, which distinguishes it from any 
other form of ulcerative action. Its surface is of a whitish-gray color, 
flush with the surface of the mucous membrane surrounding it. In 
other words, there is no apparent loss of tissue. The outline of the 
ulcer is somewhat irregularly rounded, while the mucous membrane 
surrounding the ulcer presents no characteristic distinctive features. 
The secretion from the surface of the ulcer is usually a whitish-gray 
mucus, mingled with a few epithelial cells, not however in sufficient 
numbers to render the secretion notably opaque. These peculiar 
characteristics of this form of ulceration are somewhat changed in 
the nose, owing to the fact that the impurities of the inspired air tend 
to irritate the disease process in this region, and furthermore they 
lodge upon and discolor the ulcerated surfaces. Hence, we notice a 
slight tendency to bleeding, together with a certain amount of con- 
gestion of the blood-vessels. 

The hyperplastic form presents, on inspection, small rounded 
projections from the mucous membrane of the nose ; as a rule they 
are found on one of the turbinated bodies, and are of a reddish-gray 
tinge and mammillated contour, presenting very much the appearance 



TUBERCULOSIS OF THE NASAL PASSAGES. 207 

of a papillomatous growth, differing, however, from a papilloma, in 
that they are usually much smaller, more flattened, and of a more 
regularly rounded contour. A positive diagnosis can only be made 
from a microscopical examination ; the presence of bacilli is an infal- 
lible indication of tuberculosis. 

Prognosis. — Apparently, tuberculous disease of the nose gives rise 
to no very marked symptoms, and, furthermore, does not seem to 
very greatly affect the prognosis of the general or pulmonary disease 
to which it is secondary. I think, as a rule, that the nearer a tuber- 
culous process involving the air passages approaches to the external 
world, the more virulent and hopeless the disease seems to be. This 
is not true of the nasal disease. Tuberculosis shows no marked 
tendency to extend in the nose, and indeed grows very slowly. As 
regards its curability, however, the prognosis is unfavorable. Lo- 
cal measures have accomplished little in the way of controlling the 
disease process. The total extirpation of the disease seems to have 
arrested it in certain cases, although as a rule, there has been a 
recurrence. 

Treatment. — The indications for treatment locally consist in the 
use of cleansing and disinfecting washes, together with the local 
application of iodoform in powder. If pain be present, this should be 
combined with morphine. The neoplastic form demands extirpation 
by means of the snare or the curette, as suggested by Schaffer, after 
which the base is cauterized, either by a chemical agent or the galvano- 
cautery. Halm recommends curetting or the Paquelin cautery, with 
application of pyrogallic acid; he cured several cases in this way. 
That form of treatment which seems to have afforded the best results 
is the total extirpation of the disease, when this is feasible, as is 
especially easy of accomplishment when the disease is located in the 
septum. Cartaz recommends the use of lactic acid after the method 
suggested by Krause in the treatment of laryngeal phthisis. 



CHAPTER XXVI. 

LUPUS OF THE NASAL PASSAGES. 

Lupus of the nose consists of a deposit in the tissues of the nasal 
mucous membrane of what is probably a specific virus, which not 
only produces primarily certain local changes of an inflammatory 
character, and subsequently ulcerative action, but also leads to the 
development of new centres of morbid activity in the neighboring 
tissues, giving rise to what are generally termed lupus nodules. The 
disease belongs essentially to the skin, and in the majority of in- 
stances invasion of the nasal mucous membrane is due to the extension 
of the disease from the surrounding integument. In rare cases, 
however, the disease commences in the nasal cavity, and although not 
in every instance extending to the tissues beyond the muco-cutaneous 
junction, this tendency is usually clearly manifest. Cases have been 
reported by various writers, and while many of them are given with 
insufficient data, and in others the diagnosis is open to serious ques- 
tion, yet many valuable deductions can be drawn from an analysis of 
those cases in which the diagnosis has been established, and of which 
full reports have been given. 

Etiology. — The origin of the disease is obscure, although it is 
usually associated with a notably impaired condition of the general 
health, and in some instances with unmistakable evidences of the 
strumous diathesis. It is usually said to occur more frequently in 
females than in males, although, in the above list of cases, about forty 
per cent of the sufferers were males. It is furthermore stated that it 
is essentially a disease of youth. This is not the rule, for the average 
age in the cases reported was thirty -six, the oldest case occurring at 
the age of fifty-two. In the majority of instances the nasal affection 
is due to an extension from the external nose ; this was found in about 
forty per cent of those reported, but it should be borne in mind that 
undoubtedly a very large number of cases occurs in which the skin 
affection so far overshadows the disease of the nasal cavity that no 
note is made of the latter, the notable cases being those in which the 
origin of the disease is the mucous membrane. 

Symptomatology. — A moderate amount of nasal stenosis, accord- 



LUPUS OF THE NASAL PASSAGES. 209 

ing to the extent of the disease, is always present, this symptom being 
aggravated by the formation of crusts. The discharge from the sur- 
face of the ulcer is of a thin sero-mucous character, and is never large 
in amount. Odor is rarely present, unless the disease is situated 
well up in the nasal cavity, and the crusts are retained for a sufficient 
length of time to undergo decomposition. While pain is not a prom- 
inent symptom of lupus of the skin, it may be present when the 
disease invades the nasal cavity. According to Neisser a very 
frequent complication of lupus is erysipelas. Clinical observation, 
however, as regards nasal lupus, would scarcely favor this view. 

Pathology. — The pathological changes which take place in the 
mucous membrane consist essentially of a deposit in the tissues, or 
their infiltration with small, round corpuscles of granulation tissue, 
which embed themselves between the bands of connective tissue and 
the glands, and show a tendency to follow the course of the blood- 
vessels. The infiltration, instead of occurring in a diffuse form, 
shows a marked disposition to gather itself into small masses, giving 
rise to the so-called lupus nodules. An examination of these nodules, 
in man}- cases, will show the presence of giant cells. We have here, 
then, merely a number of independent centres of inflammatory action, 
which would seem to indicate that the disease is due to the entrance 
of this specific virus, as stated by Neisser, each point of invasion 
becoming the seat of a localized inflammatory process. In addition, 
however, we notice the presence of giant corpuscles. These, as we 
know, may occur in tuberculosis, syphilis, or scrofula, hence their 
pathological significance remains still a disputed question. The 
further changes which take place in the membrane consist either in 
the reabsorption of the granulation tissue, or its progress toward the 
surface of the membrane, resulting in a breaking down of tissue there 
and the establishment of an ulcerative process, which possesses some- 
what peculiar features, in that while the waste of tissue from the 
surface is by no means rapid, the building-up process, as it were, or 
the proliferation of round cells continues ; hence we have an ulcerative 
process in which, instead of a loss of tissue, there is really an excess 
of tissue, the contour of the ulcer projecting above the normal surface 
of the mucous membrane. Schuller has observed small, round bodies 
or micrococci embedded between the granulation cells and extending 
in the form of irregular chains of micrococci into the neighboring 
connective tissues. Neisser, on the other hand, seems to think that 
Schuller is mistaken, and that the agency which causes the disease 
will sooner or later be demonstrated to be the tubercle bacillus. 

Diagnosis. — In those cases in which the disease is due to an 
extension of lupus from the external integument, of course the diag- 
14 



210 DISEASES OF THE NASAL PASSAGES. 

nosis is simple. When, however, the starting-point is within the 
nose, as Billroth has pointed out, the gross appearance of the ulcer 
varies somewhat, and it is not only " pardonable, but even unavoid- 
able" to mistake the disease for a syphilitic lesion. As a rule, our 
attention is called to the disease only after the ulcerative process 
becomes established. At this time, inspection will reveal a granular 
mass, projecting above the surface, of a reddish or brownish color, 
and covered by a brownish-gray crust, the removal of which shows 
the ulcer beneath, covered with grayish or whitish tenacious mucus. 
Upon the impact of the probe, the tissue is exceedingly soft, and the 
instrument penetrates readily, without exciting much pain or hemor- 
rhage. If the disease is located upon the septum, the probe will 
readily penetrate through the cartilage, or, if this has been destroyed, 
it passes completely through to the opposite cavity, showing the mass 
to be of a soft, pulpy, and easily yielding consistency. A positive 
diagnosis, however, cannot be based simply on the gross appearance 
of the mass. The essentially chronic character of the disease, and the 
fact that it does not yield to antisyphilitic treatment, add much to 
our information, while the positive differential diagnosis between 
lupus, sarcoma, carcinoma, and tuberculosis, the only other diseases 
with which it may be confounded, must be based on the microscopic 
characters of the tissue. 

Course and Prognosis. — Lupus of the nasal mucous membrane 
would seem to be a much less serious affection, and more amenable 
to treatment, than lupus of the skin, if we are to accept the cases re- 
ported. "While it runs an essentially chronic course, the destruction 
of tissue is by no means so rapid, and furthermore, its progress can 
be promptly arrested. Why this should be, it is difficult to state, 
unless it is that the reparative force in a mucous membrane is more 
active than in the skin, as shown by the fact that, whereas any 
extensive destruction of the skin is followed by a slow process of 
healing, and furthermore a cicatrix is likely to be very intractable, as 
in the case of a burn, in a mucous membrane, on the other hand, a 
cicatrix is a very great rarity, if it ever occurs, and even extensive 
destruction of tissue is followed by complete restoration of the part 
to its normal condition. Whatever the cause may be, the fact cer- 
tainly exists, that unless the disease has invaded too large an amount 
of tissue a cure may be expected. The duration of the disease would 
seem to have some influence. The age of the patient does not seem to 
affect the prognosis. 

Treatment. — It should be borne in mind that the disease extends 
both by the piling-up of an original lupus nodule, and also by the 
development of new centres in the surrounding tissues, this process, 



LUPUS OF THE NASAL PASSAGES. 211 

however, being extremely slow. The probabilities are that the virus 
which produces the original disease reproduces itself, and that its 
progress is due exclusively to a reinoculation. Hence it becomes im- 
portant in dealing with the disease that every possible seat of infec- 
tion should be thoroughly eradicated. Excision, however, is not 
usually demanded, as all that is necessary can be accomplished by 
either scraping or scarification, as recommended by Volkmann, or by 
the use of some caustic agent. For this latter purpose, Bresgen made 
use of chromic acid, but found it not so efficient as the potential 
cautery, while Rafin used an eighty-per-cent. solution of lactic acid. 
Each individual case, however, will afford ample opportunities of 
testing the efficacj' of any caustic used, and since there seems to be no 
danger of stimulating a renewed activity in the growth by these agents, 
they maj be pushed to the full extent. Certainly, in most cases, 
Volkmann' s spoon will be the first resort, as the tissue is of a soft and 
grumous character, and there is no danger of encroaching upon 
healthy parts. As before stated, the disease is accompanied by a 
notable impairment of the general health, and hence it scarce needs 
be added that the indications for general tonic remedies are always 
present. Hunt seems to regard arsenic as a specific, although this 
observation lacks clinical support. 



CHAPTER XXVII. 

RHINO-SCLEROMA. 

It is the almost invariable rule, that a disease process in the 
mucous membrane shows no tendency to pass over the muco-cutaneous 
junction and involve the integument. An exception to this rule, 
however, is found in that very curious disease, first described by 
Hebra, to which he gave the name rhino-scleroma, and which consists 
essentially in the development in the deeper layer of the mucous 
membrane or integment of hard, dense plates with somewhat rounded 
edges, which make their appearance either in the mucous membrane 
within the nostril, or in the integument of the alae or upper lip, the 
starting-point usually being not far from the margin of the nostril. 
After inception the disease extends by a slow but irresistible pro- 
gress, either by the enlargement of the original plates, or by new 
centres of development. 

Etiology. — Our clinical knowledge of the disease fails to throw 
any light whatever on the cause of the affection ; it apparently devel- 
ops upon patients in perfect health, and usually at a time of life when 
the vital powers are at their best, as most of the cases occurred before 
the age of forty. In one case it occurred in a boy aged fourteen. 
Mackenzie suggests that the climate or conditions of life in south- 
eastern Europe may have some influence as a predisposing cause of 
the affection, which would seem to carry the suggestion that it bears a 
certain analogy to goitre in Switzerland and to leprosy in the Orient ; 
and yet I think the fact of so many cases being reported as occurring 
in the neighborhood of Vienna is to be explained on the ground of 
the great activity of the study of skin diseases so characteristic of 
that city, and the interest excited by Hebra 's original paper, inas- 
much as later reports indicate that it is met with in most distant parts 
of the globe, as San Salvador, Guatemala, and Egypt. The possibil- 
ity of the syphilitic origin of the disease is very thoroughly excluded 
by the large number of reported cases, in which antisyphilitic treat- 
ment proved absolutely of no avail. 

Symptomatology. — Subjectively, the disease gives rise to no 
notable symptoms, in that its slow progress is attended with no local 
disturbances. There is usually some tenderness on pressure, but 



RHINO-SCLEROMA. 213 

aside from this no pain attends its development. If, however, the 
growth encroaches upon the respiratory tract so far as to interfere 
with respiration, of course considerable discomfort arises from this 
cause. Or again, when it extends backward toward the fauces, or 
possibly into the larynx, laryngeal stenosis becomes an exceedingly 
grave condition. Again, if the disease encroaches upon the oral 
cavity, it may be a source of infinite distress, as in one of Mickulicz' 
cases the oral orifice was so nearly obliterated that an external opera- 
tion became necessary, while in another of Mickulicz' cases the soft 
palate became adherent to the wall of the pharynx, necessitating an 
operation in this region to relieve the difficulty. Aside from these 
extreme conditions, the prominent symptoms to which the disease 
gives rise consist mainly in a certain degree of deformity, together 
with a feeling of stiffness and general discomfort about the integument. 
The progress of the disease is characterized essentially by infiltration 
of tissue, and no other morbid process is superadded. There is no 
tendency whatever to a breaking down, or to the formation of an 
ulcerative process. 

Pathology. — According to the original observation of Hebra, the 
essential pathological lesion which constitutes the disease consists 
of an infiltration of the chorium or papillaa of the skin, or, when it 
occurs in mucous membranes, an infiltration of the deep layer of the 
mucous membrane with small-round cells. As the result of this 
infiltration, the normal structures of the tissue are so far encroached 
upon as to give rise to an atrophic process, simply as the result of 
pressure involving the gland structures, the connective tissue, and, 
in fact, all the normal elements of the membrane and integument. 
This would seem to indicate that the morbid process is inflammatory 
in character, a view entertained by Mickulicz, although from a clinical 
standpoint there are no evidences whatever of an inflammatory proc- 
ess. Still further changes are observed by Mickulicz, which consist 
in a transformation of the round cells into spindle cells, and finally into 
a dense fibrous connective tissue. Tanturri makes the statement that 
the disease is essentially epithelial in character, and yet this view is 
probably based on an examination of a very superficial portion of the 
tissue removed, as he is entirely unsupported. Cornil finds a small, 
rod-like bacillus inclosed in a hj'aline capsule, closely resembling 
Friedlander's pneumococcus, from which he draws the conclusion 
that the disease is parasitic in its nature, although Dietrich, accepting 
the view that the disease may perhaps be due to a microbe, whether 
Cornil's or some other, yet asserts that it results more probably from 
a mixed infection than from a specific germ, and that the existence of 
the microbe is entirely adventitious, and not essential to the disease. 



214 



DISEASES OF THE NASAL PASSAGES. 



Frisch finds a small rod-sliapecl bacillus in the round cells, especially 
in those which have undergone retrograde metamorphosis. He 
believes that the connective tissue is the result of inflammation set up 
by the bacteria. 

It is interesting to note that the disease has been reproduced in 

animals, from cultures of the 
bacilli by Stepanow. The spe- 
cial changes which take place in 
the tissues are shown in Fig. 42. 
Diagnosis. — T he disease 
makes its appearance in small, 
rounded, flattened nodules, which 
may project beyond the skin, giv- 
ing rise to slight tumefaction, or 
it may be entirely beneath the 
skin or mucous membrane, with- 
out marring its normal contour. 
The tissue covering it may be of 
a healthy color, although ordi- 
narily it is of a dusky-red tinge. 
These nodules may occur in con- 
siderable numbers, entirely sepa- 
rated from one another, or they 
may be contiguous. They de- 
velop by an exceedingly slow pro- 
gress of growth, both in size 
and superficial area, extending to 
neighboring tissues. The exten- 
sion of the growth is usually lat- 
eral, although it may pile itself up into irregular masses. It is hard to 
the touch, usually tender, but does not give rise to any pain. The tis- 
sue surrounding the growth presents an absolutely normal appearance, 
there being no areola of redness, or indeed any vascular engorgement, 
unless, as occasionally occurs, the tissue over the surface of the tumor 
is slightly reddened. There is never any cedema, or swelling of the 
tissues beyond the growth. The growth itself presents to the touch 
a hard, dense, cartilaginous feeling, or even, in advanced cases, it 
gives the impression of bone. The only affections with which it might 
be confounded are sarcoma, carcinoma, and syphilis. The character- 
istic appearance of malignant disease is a soft grumous mass, bleeding 
readily on touch, in connection with an acrid discharge, which in all 
cases makes the diagnosis clear. The only manifestation of syphilis 
with which it might be confounded in the nasal cavity is a gummy 




i c I 

Fig. 42.— Rhino-scleroma. E, Thickened epider- 
mis,; L, broadened stratum lucidum ; R, rete 
mucosum ; P, papillary layer ; C, tracts of 
dense fibrous connective tissue ; I, 7, small 
cellular infiltration of derma. 



RHIXO- SCLEROMA. 215 

tumor, whose smooth outline differs essentially from the nodular 
character of rhino-scleroma, while the latter presents a characteristic 
stony feeling, never met with in the syphilitic manifestation. Any 
doubt in the diagnosis is, of course, quickly dispelled by the adminis- 
tration of antisyphilitic treatment. 

Prognosis. — The disease is essentially intractable, and is usually 
regarded as absolutely incurable. With the exception of a case of 
Doutrelepont's alone, no remedies or therapeutic measures have ever 
been resorted to, which seemed to have the slightest effect in control- 
ling its progress. 

As regards life, however, the prognosis is favorable, as the disease 
is purely a local one, for its onset does not necessarily impair the 
general health, and involves no tendency to death, except when it 
interferes with important functions by its mere location, as for in- 
stance when it extends to the larynx, giving rise to stenosis and 
threatened suffocation. With this exception, the disease apparently 
does not shorten life, and simply continues a source of discomfort to 
the victim until death occurs, usually from intercurrent disease. Thus, 
in a case of Schulthess', the disease had extended so far at the end of 
twenty-four years as to involve the integument of the external nose, 
upper lip, the upper and lower pharynx and the larynx, giving rise 
to stenosis of the larynx, demanding tracheotomy, the patient being 
still living at the time of the report. This would appear to be the 
limit to which the disease ever extends. When having its origin in or 
near the nostril, it extends to the external nose, upper lip, and in rare 
cases encircles the mouth. After entering the nasal cavity, it travels 
slowly backward, involving the pharynx, soft palate, and larynx, after 
which its lateral extension seems to cease, while its remaining energy 
is expended in adding to the already existing tumefaction. 

Ganghofner, however, believes that the disease may sometimes 
originate and develop in the larynx and trachea, giving rise to stenosis, 
without the nose and mouth being affected. 

Treatment. — A case of Schlapoberski's was cured by treatment 
after Boeck's method, to wit: the growth was curretted, nitrate of 
silver applied, and the wound painted with a ten-per-cent solution of 
iodoform collodion. The treatment lasted seven months. There was 
a complete cure and no return after four and a half years. Tscher- 
nogubow had excellent results from the galvano-cautery, and Fedorow, 
with subcutaneous injections of a ten-per-cent solution of chloride 
of zinc. Mourek used with some slight success injections of from two 
to sixty millimetres of nuclein. He gave from seven to twenty-nine 
injections. Sturowenrow used injections of arsenic from 1 : 100 to 
12: 100; he recommends the treatment, as he had good results. 



CHAPTER XXVIII. 

NASAL POLYPUS, OR MYXOMA. 

This term nasal polypus is given to a variety of growths met with 
in the nasal cavity more frequently than any other form of neoplasm. 
They occur either singly or in groups, and present a grayish, semi- 
opaque appearance. They have been recognized by medical writers 
from the earliest times and occur more frequently than is generally 
recognized. My own experience shows that of one thousand four 
hundred and eighteen cases of ordinary catarrhal disease seen in pri- 
vate practice, exclusive of my hospital cases, one hundred and thirty- 
four showed the presence of fully developed polypi, or about one case 
of polypus for every eleven cases of ordinary catarrhal trouble. 

Pathology. — The prevailing type of these tumors is that of pure 
myxoma. According to pathologists, the external surface of the tumor 
is covered by the epithelial layer of the mucous membrane lining the 
nasal passages, the epithelium frequently beiDg ciliated. Within this 
envelope is a delicate reticulum of connective tissue in which are 
embedded stellate myxomatous and embryonic connective-tissue cells ; 
the bulk of the tumor being made up of a gelatinous intercellular sub- 
stance containing very largely of mucin. 

Cystoma, as will be seen when we come to the discussion of that 
form of tumor, is met with very rarely in the nasal cavity, but cystic 
metamorphosis is not an infrequent occurrence in nasal polypi. This 
would seem, therefore, to go far toward demonstrating that glandular 
structure is present in the myxomata; acording to Robin, cystic 
degeneration is due to a general hypertophy of the acinus, together 
with an atrophy of its duct, as the result of which there is an increased 
secretion, which, failing of free exit, collects in the gland, whose 
walls gradually yield to the pressure and become dilated. That this 
process is not constant, however, has been shown by Billroth, who 
states that cystic degeneration does not necessarily depend always 
upon obstruction of the gland duct, but may result from certain 
changes in the epithelial cells lining the glands, their ducts remaining 
patent. 

Attachment. — All authorities unite in the statement that these 



NASAL POLYPUS, OR MYXOMA. 217 

growths spring, as a rule, from the mucous membrane covering the 
middle turbinated bone. Zuckerkandl made an exhaustive study of 
the location of these growths, in thirty-three cases which he examined 
post mortem. 

In thirty of his cases they had their origin upon or in the imme- 
diate neighborhood of the middle turbinated bone, the other three 
cases springing from the septum. 

Etiology. — It is difficult to assign any definite cause for the oc- 
currence of mucous polpyi. They are certainly not due to any im- 
pairment of general health or constitutional diathesis, for, as a rule, 
they occur in patients in vigorous health. 

I am disposed to think that the most rational explanation of the 
development of these growths is that the mucous membrane covering 
the middle turbinated bone is of very soft and delicate consistency, 
and is actively concerned in the respiratory function of the nose, viz. , 
serous exosmosis, and that under certain conditions the membrane 
becomes saturated or water-soaked, as it were, in such a manner as to 
lead to the development of this peculiar myxomatous condition. As 
to what peculiar nutritive disturbance in the meshes of this tissue 
predisposes to this form of degeneration, I have no suggestion to 
make. The view is based entirely on the fact of the frequent devel- 
opment of nasal polypi in those curious cases of profuse watery dis- 
charge from the nasal mucous membraDe, already described in the 
chapter on Nasal Hydrorrhcea, which occurs, not as the result of 
the impact of vegetable spores upon the nasal mucous membrane, 
as in ha} r fever, but is perennial and diurnal; that is, it occurs 
usually at certain hours every day, through the whole year. In the 
early stages of the attacks, no morbid conditions of the mucous 
membrane can be discovered, as a rule, but in a number of instances 
which have come under my observation, after the disease has per- 
sisted for a certain length of time, typical mucous polypi have de- 
veloped on the membrane covering the lower border of the middle 
turbinated bone, which, after development, subject as they are to the 
action of gravitation, together with the traction influence of blowing 
the nose, and the to-and-fro movement of the current of air in respi- 
ration, gradually sag down as it were, and, becoming filled with serum, 
drag on their original attachment to the membrane above, until a 
pedunculated tumor is developed (see Fig. 43) . A somewhat similar 
view is suggested by Hopmann, who thinks the primary lesion which 
leads to the development of the growths is in some impairment of 
circulation in the efferent vessels, resulting in an cedematous condi- 
tion of the membrane. Billroth, whose views as to the glandular 
character of these growths is adopted by Zuckerkandl, considers that 



21! 



DISEASES OF THE NASAL PASSAGES. 



the tumor originates as an adenoma, but later some of the ducts be- 
come occluded, resulting in a myxomatous degeneration of the glan- 
dular tissue. These growths have been observed to develop after 
fracture of the vomer. They frequently accompany syphilitic necro- 
sis either of the vomer or of the turbinated bones. 

They are more common in males than in females. As to age, they 
occur most frequently between twenty and thirty, and rarely before 
the age of fifteen. Lennox Browne is undoubtedly justified in mak- 
ing the broad statement that " polypi may occur at almost any age." 




Fig. 43.— Nasal Polypi. (Zuckerkandl ) b, Infundibulum ; c, cyst of the mucous membrane. 



Heredity has little if any influence on the development of these 
tumors. 

A deformed septum is not infrequently associated with the exis- 
tence of nasal polypi, and probably predisposes to their development, 
in the same manner as to the development of hypertrophic rhinitis. 
In these cases the tumors are usually found in the more roomy cavity, 
though in rarer cases in the obstructed side. 

Symptomatology. — The first and earliest symptom that occurs in 
connection with these growths is intense irritation in the upper 
passages of the cavity, and more or less violent attacks of sneezing, 
accompanied with watery discharge. These watery discharges have 
their source in the mucous membrane proper, and not in the polypus, 



NASAL POLYPUS, OR MYXOMA. 219 

as is often asserted. This symptom is due probably to a paresis of 
the vasomotor control of the respiratory exosmosis. The fluid, mak- 
ing its way through the membrane, produces an abnormal irritation 
of the parts, causing burning or itching sensations, referable to the 
bridge of the nose. As the growth develops in size, nasal stenosis 
sets in, which is at first most marked in the upper portion of the 
cavity, a form of stenosis which is oftentimes distressing in the ner- 
vous irritability which it causes. The stenosis in this region is due 
more to the swelling of the membrane than to the polypi themselves. 
As they increase in size, however, they gradually obstruct the entire 
nose. They commence, as a rule, in one fossa, but I think it is the 
rare exception that they do not develop sooner or later on the other 
side. 

Loss of the sense of smell occurs early in the development of the 
disease, not entirely as the result of obstruction, but rather from a cer- 
tain disorganization which occurs in the mucous membrane lining the 
olfactory region. The stenosis varies notably under atmospheric con- 
ditions, which has given rise to the assertion by probably a majority 
of writers that these growths possess a certain hygroscopic character ; 
that they absorb moisture and become swollen on damp days. I do 
not think a myxomatous growth possesses the power of absorbing 
moisture, and I attribute this symptom to the swelling of the mu- 
cous membrane lining the nose, owing to the excessive irritability 
caused by the presence of the growths. As a consequence, these 
patients become exceedingly susceptible to changes in the weather, 
all the symptoms being notably aggravated during the cold and damp 
days of spring and fall, while the milder seasons afford notable relief. 
The discharge from the nose is usually rather profuse, and while the 
disease is confined to the nasal cavity proper, is of a thin, watery 
character. 

In cases of long standing there is frequently a profuse discharge 
of bright-yellow fluid pus. I doubt very much if a mucous polyp 
whose source is in the nasal cavity proper ever gives rise to a purulent 
discharge, and a discharge of this kind should always be understood 
as indicating the supervention of purulent disease of the antrum or 
of one of the accessory cavities. The method of development of this 
complication is quite simple. The orifices of these cavities having 
become occluded by the presence of the growths, the normal secretion 
accumulates to such an extent that a purulent inflammation is the 
natural result. Occasionally a mucous polyp may develop in the 
antrum, or possibly it may make its way into the antrum from the 
nose. 

As already stated in the discussion on nasal reflexes, no morbid 



220 DISEASES OF THE NASAL PASSAGES. 

lesion of the nasal cavities is more frequently the source of reflex dis- 
turbances than nasal polypus ; hence, asthma and hay fever are asso- 
ciated with these growths in a large proportion of cases, although 
Hack considers polypi as rather an infrequent intranasal condition, 
in cases of this disease. This question, however, is more properly 
discussed elsewhere. For the same reason, ocular symptoms not in- 
frequently occur in connection with the presence of these growths. 
The aural symptoms due to nasal polypi are to be regarded not as 
reflexes, but as direct symptoms due to stenosis with interference of 
normal respiration, their method of development being identical with 
that described in the chapter on hypertrophic rhinitis. 

Suppurative otitis I have not seen, although this complication has 
been observed by Barth. Tinnitus aurium also is mentioned by 
Kobinson as a complicating symptom. Laryngitis and bronchitis 
are very liable to occur sooner or later, as the result of the nasal 
stenosis. The voice is affected according to the extent of the nasal 
obstruction. To one familiar with these cases, I think the voice pre- 
sents characteristics which enable us to recognize a case of nasal 
polypus almost immediately on hearing the voice. The facial expres- 
sion is also characteristic, in that there is that peculiar thickness 
about the bridge of the nose which always suggests nasal stenosis, 
whether from a cold in the head or other causes. Deformity of the 
external nose is never present in a pure myxoma, the growths as 
they fill the cavity oozing out, as it were, from one or the other 
nostril, rather than pressing against the lateral walls. 

Diagnosis. — The recognition of a nasal polypus depends entirely 
on ocular inspection, which should always be made with sunlight or 
an equally powerful illuminator. As an aid to diagnosis, we should 
always make use of cocaine, to contract the blood-vessels and open 
up the cavity for thorough inspection. If a polypus is present it will 
be seen to present a striking contrast in color with the normal nasal 
mucous membrane of the passage, while it also presents a tumefaction 
not belonging to the normal contour of the cavity. The color, further- 
more, of a polypus resembles that of no other growth or abnormal- 
ity found in the nasal cavity. It is of a bluish-gray color, with a 
bright, shining, glistening surface, not unlike, as before suggested, 
the pulp of a grape, but with the addition of a bluish rather than a 
greenish tint. 

If the growth has developed so far as to protrude below the middle 
turbinated bone, we have an additional aid to diagnosis, in the fact 
that it becomes freely movable in the cavity ; hence, in these cases a 
probe should always be used, to test this mobility. Furthermore, on 
the impact of a probe it is easily indented, showing a certain re- 



NASAL POLYPUS, OR MYXOMA. 221 

siliency by which the indentation disappears readily on the removal 
of the probe. A mistake in diagnosis I think need never occur with 
a proper illuminating apparatus. A deflection of the septum present- 
ing near the nostril might be mistaken by the inexperienced for a 
nasal polyp. Its density and immobility are always sufficiently 
evident to render such a mistake unnecessary. The same may be 
said of ecchondromata and exostoses. Abscess of the septum may 
very closely simulate a mucous polyp, but this affection presents a 
soft, fluctuating tumor, whose character can easily be ascertained by 
careful manipulation of the probe, or, better still, by puncture with a 
bistoury. 

Pkognosis. — The existence of nasal polypi involves no serious dan- 
ger to life, though they may give rise to bronchitis, asthma, hay fever, 
etc. If not treated they develop with rapidity, as the polyp-breed- 
ing surface increases in area and the nasal cavities become completely 
stenosed. There is no tendency to a spontaneous cure, hence the 
prognosis is mainly dependent upon the success of treatment. A 
question of perhaps more interest is, whether a myxomatous tumor 
preserves its original type, or whether it may undergo changes of a 
malignant character. Billroth says that this idea has been accepted 
as an article of faith, rather than proven. In this same work, how- 
ever, he cites a case in which the polyp was at first mucous, and after 
operation apparently took on a carcinomatous degeneration. In a 
subsequent work, however, he goes so far as to state that the tissue 
found in nasal polypi is frequently adeno-sarcomatous. A review of 
the cases reported gives undoubted evidence that these tumors may 
undergo not only sarcomatous but probably carcinomatous degenera- 
tion, as the result of operative interference. So far as I know, there 
is no well-established case in literature of nasal polypus having un- 
dergone malignant degeneration spontaneously. 

Treatment. — The successful treatment of mucous polypi in the 
nose depends upon their complete ablation, either by destruction or 
by extirpation. 

Certain chemical agents are recommended to be introduced directly 
into the mass, by means of a hypodermic syringe, or by simple punc- 
ture. Thus, Frank Donaldson advises that chromic acid be carried 
directly into the body of the tumor by means of a pointed glass rod, 
while Bell accomplished the same purpose by injecting into each 
growth, by means of a hypodermic syringe, a solution of tannic 
acid, twenty grains to the ounce. In the same manner Maxwell has 
had success by the injection of tincture of iron. The destruction of 
a polyp in situ after these methods may undoubtedly be successful, 
but it results in a necrotic mass of tissue, which remains in the 



222 DISEASES OF THE NASAL PASSAGES. 

cavity, a putrid, offensive body, until it sloughs away. In those 
cases in which twenty, thirty, or even more separate growths occur, 
this method would involve an unnecessarily long and distressing 
course of treatment. I think it offers no advantage whatever, sufficient 
to warrant our subjecting patients to it. The only successful method 
of dealing with these growths is to extirpate them by surgical means. 
The evulsion of nasal polypi by means of forceps is the oldest and 
the one which has come into widest use, but I believe this to be a 
procedure which should never under any circumstances be resorted 
to. As regards special directions for searching for the polypus, and 
for seizing its pedicle, I am confident that no operator ever possessed 
either the skill to differentiate, by touch with the forceps, a nasal 
polypus from the mucous membrane, or sufficient manual dexterity 
to enable him to seize the pedicle. The instrument, at its best, can- 
not be sufficiently delicate to allow large freedom of action in the 
nose. As a rule, it will be carried in with its blades open, and then 




Fig. 44.— The Author 



be closed upon whatever may happen to fall within its grasp. The 
essential feature of any operation for the extirpation of nasal polypi 
is that they shall be removed without injury to the healthy tissues. 
For the accomplishment of this purpose no measure is comparable 
to the cold wire snare. In this instrument the loop of steel wire is 
slipped over the polypus, carried as far toward its base as possible, 
and then drawn within the tube and the growth severed. The steel 
wire gives us a loop of sufficient stiffness to enable us to carry it to 
any portion of the nasal cavity, and over any growth which it is de- 
sired to seize. Jarvis' original snare ecraseur (see Fig. 31), being 
somewhat slow in its action, led me to advise the instrument shown 
in Fig. 44, the manipulation of which will be readily appreciated at 
a single glance. The loop, being placed in postion over a growth, 
is drawn home by a single motion, and the tumor severed from its 
attachments. 

The galvano-cautery has had many advocates for its use in the 
removal of these tumors. By this agent, a growth may be directly 
destroyed or its attachments severed by the galvano-caustic loop. 



NASAL POLYPUS, OR MYXOMA. 223 

Of late years I think this device finds little if any indorsement, those 
who use the chemical cautery contenting themselves with making use 
of it to cauterize the base of a growth, after its removal by other 
methods. The difficulty of putting the soft and pliable platinum 
wire around the polypus, and the unwieldy nature of the cautery 
handle as well as the uncleanliness attending the use of the thermo- 
cautery, and the inflammatory reaction following the operation, 
combine to make this procedure less desirable than the employment 
of the cold wire snare. The cold wire snare affords the most efficient 
and least painful method of operating, and also more completely 
avoids anj' dangers or complications that may arise than any other 
device. The instrument already figured as the author's possesses 
the advantage of delicacy of construction and ease of manipulation, 
while, at the same time, it affords an unobstructed view of the manip- 
ulation of the loop in the nasal cavity. The still further advantage I 
think should be mentioned of the three-fingered manipulation, which 
undoubtedly affords the nicest adjustment of the loop over the growth, 
and the quickest abscission of the tumor, for it is properly a cutting 
instrument rather than a snare. 

Operation. — In operating on nasal polypi, the use of cocaine is 
indispensable, both as producing local anaesthesia, and so far con- 
tracting the blood-vessels of the mucous membrane as to largely elim- 
inate the possibility of hemorrhage. For this purpose, a twenty-per- 
cent solution should be used as producing most rapid and complete 
insensibility. This should be applied by means of an atomizer. In 
cases in which the cavities are more or less completely filled with the 
growths, the thorough anesthetization of the membrane is impossible, 
although in those cases much can be accomplished by the delicate 
manipulation of a pledget of cotton on a probe, dipped in the solution 
and carried in as far as possible. When a mucous polyp is visible, 
I think it in all cases feasible to carry a loop over it. Now, it is not 
a matter of importance whether the whole polyp is extirpated at the 
first operation or not. Bearing in mind that, as a rule, its attach- 
ment is beneath the middle turbinated bone, the loop is carried in 
between the growth and the septum, its lower border being below the 
lower end of the tumor, when it should be turned to a horizontal plane 
and by a gentle to-and-fro motion slipped upward, until as much of 
the polyp as possible is engaged within its lumen, when the loop 
should be drawn home. Proceeding in this manner, I think in the 
majority of instances it will be found an easy matter to clear one or 
both cavities of all presenting growths at a single sitting, provided 
there are no obstructing deformities of the cavities, such as a de- 
flected septum. Hemorrhage rarely if ever attends this method of 



224 DISEASES OF THE NASAL PASSAGES. 

operating in the hands of a skilful manipulator, and therefore need 
not complicate the procedure, for the blood supply in the polypus 
itself is exceedingly scanty, and the mucous membrane, the usual 
source of bleeding, need not be injured. As the operation proceeds, 
and deeper portions of the cavity are opened up, it is well to repeat 
the applications of cocaine, as of course much discomfort is saved 
the patient in anaesthetizing the free portion of the cavity, even if the 
anaesthetic does not reach completely the part filled by the growth. 
When the tumor lies well back in the passage, and cannot be easily 
reached by the snare, although visible, the manipulation will be much 
aided by the use of McKay's slender ear forceps, shown in Fig. 45. 




Fig. 45. — McKay's Forceps. 

By this instrument the growth can be easily seized, its bite being 
mouse-toothed, and drawn down into full view, when the loop can be 
readily adjusted over it. The removal of these growths, however, 
seems to loosen, as it were, those tumors which have been apparently 
crowded up in the sinuosities beneath the middle turbinated bone, so 
that they are enabled to drop down into the cavity. Hence, it is best 
to repeat the sitting at the end of a week, when oftentimes quite a 
number of apparently new growths will have shown themselves. 
These are not new polyps, however, but have simply allowed thein- 
seles to come into sight, and moreover have undoubtedly filled up and 
enlarged simply from the fact that space has been afforded them. 
The weekly sittings should be continued until an inspection shows 
a cavity entirely free from polypi, after which the patient should be 
seen once a month for probably four or five months, at the end of 
which time a radical cure in the large majority of cases can be assured. 
A certain amount of importance is attached by some to the cauter- 
ization of the base of the growth, to prevent its recurrence, giving 
preference for this purpose to the galvano-cautery . I have never been 
able to recognize the base from which a polyp has been severed, and 
therefore think it unwise to subject healthy tissues to injury, in the 
blind attempt to cauterize a region that cannot be seen. Further- 
more, I do not believe it is necessary, for, as before intimated, if we 
thoroughly extirpate the growths, they do not recur. The assertion 



NASAL POLYPUS, OK MYXOMA. 225 

that in a recurrence of these growths they take on a new development 
from the fact of their being more dense and consisting largely of con- 
nective tissue, has already been referred to. I have in no single in- 
stance observed any such tendency, after operating with the cold snare, 
the polypus at the end of four years showing the same type as the origi- 
nal virgin growth, and I am confident that this fibrous development is 
entirely the result of traumatism in the use of forceps or the galvano- 
cautery. I make this assertion broadly, for it is based on a large ex- 
perience in which no single exception to the rule has been observed. 
15 



CHAPTER XXIX. 

FIBKOMA OF THE NASAL PASSAGES. 

A cuksoky examination of the literature of nasal growths would 
seem to suggest that a fibrous tumor in the nasal cavity is an exceed- 
ingly rare event. Thus, Mackenzie's study of the subject is based on 
an analysis of three cases, one of which occurred in his own practice. 
A more careful investigation, however, shows us that whereas this 
form of neoplasm is met with more frequently in the naso-pharynx 
than in any other portion of the upper air passages, its location in 
the nasal cavity proper is by no means an uncommon occurrence. 
Moreover, the establishment of this fact is not in any way due to the 
development of an interest in diseases of the upper air passages, 
because a majority of the cases found in literature were reported long 
before the diseases of the nasal cavity became the subject of that in- 
dustrious investigation which characterizes the present day. 

Etiology. — Morbid processes in the nasal mucous membrane are 
essentially those which involve connective-tissue changes ; hence the 
highly vascular character of the pituitary membrane, together with 
the intense functional activity which belongs to it, would seem to 
provide especially favorable conditions for the development of fibro- 
mata. It is a well-known fact that the uterus is the most frequent 
site of fibroid development, which Billroth very ingeniously explains 
on the theory that fibromata arise from the nerve sheaths and the 
adventitia of the small arteries, the nerves disappearing, while the 
arteries remain, and hence the uterus, whose nerves and vessels 
undergo such great changes during menstruation and preganancy, 
offers a favorable site for this form of morbid growth. The daily and 
hourly changes in the turgescence of the blood-vessels of the nasal 
membrane, together with its excedingly rich nerve distribution, would 
seem to show the existence of a certain predisposing cause of the 
disease under consideration in this region also. The immediate 
exciting cause, however, is not so easily explained, although in one 
case, an inflammatory process seems to have been the active cause of 
the morbid growth, while in another the development seems to have 



FIBROMA OF THE NASAL PASSAGES. 227 

been due to traumatism. In the negro races, as we know, fibroma of 
the uterus is exceedingly common. As regards the nasal cavity, how- 
ever, race would seem to have no influence. Sex, on the other hand, 
would seem to have a notable influence in predisposing to the disease, 
in that rather more than two-thirds of the cases reported occurred in 
males. Age would seem to exercise a certain influence also, in that 
the disease belongs to the earlier periods of life, usually from fifteen 
to thirty. 

Symptomatology. — As already noted, the disease probably com- 
mences in the nerve sheaths and blood-vessels, the nerves being de- 
stroyed, while the vessels remain. Hence pain is rarely a symptom 
in the early part of the disease, although it may develop later, as the 
result of pressure. Epistaxis, on the other hand, is perhaps one of 
the most constant and frequent evidences of the disease, due in most 
instances, undoubtedly, to the vascularity of the growth itself. In 
the large majority of instances, the source of the bleeding is in the 
tumor itself. This symptom recurs with considerable frequency, and 
may become an exceedingly grave symptom. Nasal stenosis, with a 
more or less profuse muco-purulent discharge mixed with blood or 
clots, is of course a frequent attendant upon the development of these 
growths. Perhaps no form of neoplasm develops and spreads with a 
more unrelenting progress than a fibroma ; neither tissue, cartilage, 
nor bone seems to offer the slightest hindrance to its growth. Hence, 
according to its original location and the direction of its growth, ex- 
ternal deformity usually develops. Headache seems to have been 
present in a number of these cases, probably of a neuralgic character. 
Anosmia occurs in the majority of instances, as the direct result of 
stenosis, while, as its indirect result, slight impairment of hearing is 
present in all cases, and in many this symptom is very prominent, 
due probably to the interference with normal nasal respiration, al- 
though, if the growth extends into the naso-pharynx, there may be 
direct pressure upon the oriface of the Eustachian tube, while, as the 
result of this extension, the movements of the pharynx in deglutition 
may be seriously interfered with. 

Pathology. — Fibroma of the nose, from a pathological point of 
view, differs in none of its essential features from the same form of 
neoplasm as found in other regions of the body. It is composed of 
a dense network of fibrous tissue, containing within the meshes or 
interspaces, scattered here and there, either between the bundles of 
fibres or between individual fibres, spindle-shaped or stellate cells, 
together with a finely granular homogeneous basement substance. 
The density of the tumor varies to a certain extent, dependent some- 
what on the relative proportion of the cellular substance, and the 



228 DISEASES OF THE NASAL PASSAGES. 

fibrous tissue. The starting-point of the growth is in the nerve 
sheaths and aclventitia of the small arteries. 

Sarcomatous degeneration is a not infrequent occurrence in these 
cases, and yet the presence of sx^indle cells is not always to be re- 
garded as an evidence of this change, for this element may persist for 
a long time, and even increase, and yet the growth itself, from a clin- 
ical point of view, show no evidence whatever of malignancy. Thus, 
Ingals operated on a pure fibroma, which recurred at the end of iiYe 
years. The tissue removed by the second operation proved to be in 
part composed of from one-fifth to one-half cellular elements. 

In making a microscopic examination, it is a matter of some im- 
portance that a number of specimens be studied, in order to establish 
the definite relation between the fibrous and the cellular elements, as 
these growths may not only undergo sarcomatous degeneration, but 
there may be a mixed growth from the onset. Aside from sarcoma, 
we have fibrous tissue combined with other elements, giving rise to a 
myxo-fibroma, adeno-fibroma, chondro-fibroma, and osteo-fibroma. 
Of these forms, myxo-fibroma is not infrequently met with in the 
nose. Probably, in most cases, this growth is the result of harsh 
surgical measures for the relief of simple myxoma. A case of Dixon's, 
so far as I know, is the only instance on record of a chondro-fibroma. 
Of the other varieties, no cases have been reported as occurring in 
the nasal cavity. 

Diagnosis. — With our present means of exploring the nasal pas- 
sages, by depleting the blood-vessels through the action of cocaine, 
a fibroma whose origin is in the nasal cavity proper should ordinarily 
be brought under ocular inspection through the anterior nares, even 
when situated well back in the chambers, if the secretions be deftly 
removed, by means of a cotton pledget, and the parts thoroughly 
cleansed. If this is not feasible, it can be brought under inspection 
by means of a rhinoscopic mirror in the fauces. When seen, its gross 
appearance is characteristic and usually recognized with facility. 
The surface of the growth is irregularly rounded or lobulated, smooth 
and glistening in appearance, and presents a decidedly reddish-pink 
color. The growth is of a dense, resisting character, and need not 
usually be mistaken for any other neoplasm, the diagnosis being based 
on the subjective symptoms of stenosis, and much aided by external 
deformity, when it exists, together with the repeated attacks of epis- 
taxis, which are characteristic, and the peculiar color and gross 
appearance. 

While the diagnosis of the character of the growth is quite easy, 
the determination of its origin requires a more careful examination. 
It is a matter of no little importance to determine whether the growth 



FIBROMA OF THE NASAL PASSAGES. 229 

springs from the nasal cavity proper, or from the vault of the 
pharynx, for, as we have seen, nasal fibromata are comparatively 
rare, while the upper pharynx is a somewhat frequent site for their 
development, the operative procedure indicated in the one case being 
very different from that in the other. A pharyngeal fibroma usually 
gives rise to bilateral stenosis ; while in its early stage, and usually 
till the tumor has grown to considerable size, a nasal fibroma causes 
unilateral stenosis. Dolbeau seems to attach considerable importance 
to this diagnostic symptom, but takes the ground that the unilateral 
stenosis characterizes the naso-pharyngeal growth. I am disposed 
to think, however, that a tumor springing from the base of the skull 
will give rise to obstruction of both posterior nares, as it grows down- 
ward, forming a curtain, as it were, much earlier than the nasal tumor 
having its origiu in one passage. Furthermore, the peculiar frog-face 
is a characteristic of the nasal growth, a feature usually not so 
prominent in the pharyngeal disease. The determination, then, of 
the site must be based on such careful study of the parts as the 
size of the growth permits, by both rhinoscopic examination and pal- 
pation, together with the use of the probe, in connection with a care- 
ful estimate of the subjective symptoms. In the majority of cases, 
the growth springs from the upper portions of the cavity, either from 
the ethmoid bone or from the region of the superior turbinated, al- 
though in several cases its origin was in the floor of the nares, while 
in Fischer's and Dolbeau' s cases it sprang from the septum. 

Prognosis. — On account of its location and its nearness to vital 
parts, a fibroma of the nose will eventually prove fatal, unless sub- 
jected to successful operative interference. That, however, a favor- 
able termination may be expected from this interference, is very 
strikingly shown by the results of the cases reported. We find that 
the growth was successfully extirpated in all but four, while in four 
death occurred, in all cases as the result of the operation. 

Treatment. — No local treatment has ever been demonstrated to 
possess any power whatever in arresting the growth of these tumors. 
A surgical operation is always necessary for their removal. If the 
growth can be embraced in the loop of a cold-wire snare or the 
galvano-cautery ecraseur, probably we possess no better method for 
its removal. The choice of the cold or the heated wire, of course, 
will be dictated largely by the individual preferences of the operator. 
It has been almost the universal practice to use No. 5 steel piano 
wire in the snare. It certainly would be wiser, in fibroma of the 
nose, to make use of the larger sizes, in order to avoid the possibility 
of any accident happening, as did in a case of Seller's, by the break- 
ing of the wire. If the growth is of large size, there is no objection 



230 DISEASES OF THE NASAL PASSAGES. 

to removing it piecemeal, if this is feasible. When, however, this 
cannot be done, Casselberry's device can be resorted to, which con- 
sists in incising the growth by means of the galvano-cautery knife, 
after which the snare can be easily adjusted over the two tongues, 
as it were, which are thus produced. In several cases evulsion was 
practised, and apparently with success, but it is a method of opera- 
tion which would scarcely be considered a proper surgical procedure 
at the present day. In many cases, however, one of the operations 
alluded to in the chapter on the External Surgery of the Nose, will be 
necessary. In one case, the soft palate was slit, and the growth 
dragged down, and cut with a knife, while in another access to the 
cavity was obtained, by opening through both the soft and hard 
palate; this latter procedure, however, was resorted to through a 
mistaken idea that the growth was naso-pharyngeal. 

The great danger which attends an operation on a nasal fibroma, 
lies in the excessive hemorrhage. We possess no means of eliminat- 
ing this danger, as it is concomitant of this form of tumor, and must 
be managed by the rules which govern general surgical procedure. 



CHAPTER XXX. 

OSTEOMA OF THE NASAL PASSAGES. 

We use the term osteoma to describe that very grave form of os- 
seous neoplasm, which, having its origin in the upper portion of the 
nasal cavity, or in one of the accessory sinuses, extends slowly but 
surely, until it invades neighboring parts, or projects beyond the 
cavity, producing oftentimes most unsightly external deformity. In 
most cases, these tumors, in their development, retain connection with 
the parts from which they originate, constituting what are ordinarily 
called living osteomata. In other cases this connection may be sev- 
ered as the result of a blow or some unknown cause, and the fragment 
remain imprisoned in the cavity, as a source of irritation, constitut- 
ing what is known as a dead osteoma. 

While it is not an especially rare occurrence for the nasal cavity 
to be invaded by an osseous tumor which has its origin in parts be- 
yond, a neoplasm of this form, developing primarily in this region, 
is much less frequent. Its occurrence is evidenced by such unmis- 
takable signs that we can easily understand how it should have 
been recognized by the earliest writers on medicine, and yet their 
observations were so lacking in definite data as to add little to our 
clinical knowledge of the disease. 

Etiology. — It is difficult to assign any direct cause for these 
growths, and any suggestion would be merely speculative. They 
ordinarily commence somewhat early in life, usually at from fifteen 
to twenty, although they have been known to begin much later. In 
the majority of instances they occur in males, although why this 
should be it is difficult to say. 

Symptomatology. — External deformity seems to be the earliest 
symptoms to which these growths give rise. This is due to the fact 
that the growth has its origin in the upper portion of the nasal 
cavity, and extends toward the face, even before it involves the lower 
meatus. In the same way, it very early shows a disposition to invade 
neighboring cavities, its most frequent track, perhaps, being through 
the ethmoid cells to the orbit, giving rise to exophthalmos. Epis- 
taxis does not usually occur. Pain, however, due to pressure on 



232 DISEASES OF THE NASAL PASSAGES. 

some of the sensory nerves, is of frequent occurrence. Nasal stenosis 
is of course dependent upon the size and direction which the growth 
takes. Discharge from the nose is not usually a prominent symptom. 

Pathology. — These tumors are met with in two varieties, the hard 
and soft. In one case the growth is made up entirely of compact 
tissue, in the other of cancellous tissue, covered by a thin shell of 
hard bone. The starting-point of the morbid process in these tumors 
is still somewhat a matter of speculation. They may arise from the 
ossification of the islands of cartilage, which are occasionally found 
as survivals of the original process by which the bones of the skull 
are formed ; or their starting-point may be in the minute centres of 
calcification, which Verneuil has demonstrated to exist in the mucous 
membrane. Whichever of these theories may be true, the source of 
these growths is undoubtedly in the periosteum. There is good 
ground for supposing that their primary origin is always in one of 
the accessory sinuses. Speaking generally, we are safe in accepting 
Dolbeau's view, that they may arise from any portion of the mucous 
membrane, either of the nose or accessory cavities ; their frequenc}' 
in the accessory cavities, and especially in the ethmoid, being closely 
connected with the peculiar tendency to calcareous degeneration al- 
luded to in the discussion of the pathology of disease of the antrum. 

The surface of these tumors is irregularly lobulated and covered 
with normal mucous membrane, the deep layer of which forms the 
periosteum. The outer layer of the tumor is invariably formed of 
compact bone tissue, differing in no essential degree from normal 
bone of this character. In many cases, the entire tumor is composed 
of this tissue, while in others, as we penetrate beneath the surface, 
we come upon the cancellous tissue, still preserving the normal type, 
and differing from it only in that the Haversian systems are some- 
what distorted, and perhaps, in most instances, crowded together, 
as it were, into a denser tissue than the normal. At its onset, the 
development of these tumors is equal and peripheral, giving a cylin- 
drical and rounded contour. As they impinge upon the bony walls 
of the cavity, this rounded shape is interfered with in such a way 
that the surface becomes nodulated, and, furthermore, prolonga- 
tions develop in the direction of least resistance. As the tumor de- 
velops, the point of attachment becomes relatively very small, and as 
it is composed of spongy tissue it is easily broken off, either by the 
weight of the tumor or by a blow. 

Diagnosis. —Examination of the parts should enable us to recog- 
nize the existence of the tumor at a comparatively early stage ; the 
presence of bone is in every case easily determined, by means of a 
probe, or, when feasible, by the insertion of the finger. If there be 



OSTEOMA OF THE NASAL PASSAGES. 233 

any doubt as to its structure, the exploring needle is sufficient to re- 
move this. The nicer points of diagnosis, such as between an osteoma 
and an osteo-sarcoma, can only be determind by removing a portion 
of the tumor and subjecting it to a microscopical examination. The 
growth is firm and absolutely immovable, except in those cases in 
which spontanous separation has occurred ; hence its mobility must 
always be accepted as evidence of this occurrence. If the tumor has 
remained in the cavity for a prolonged period of time after separation, 
it may present the appearance of a rhinolith ; the mucous membrane 
having sloughed away, there is a profuse and offensive discharge. In 
this case, the diagnosis would only be cleared after the removal of 
the growth. 

Pkognosis. — After spontaneous separation, there is no tendency to 
recurrence, the only condition to deal with being the removal of what 
is now merely a foreign body in the nose. When this fortunate ac- 
cident does not occur, these growths may attain large size and 
involve very serious external facial deformity, and yet the prognosis 
seems to be favorable in the very large majority of cases, in that sur- 
gical interference is usually attended with complete success. 
1 Treatment. — An external operation in most instances will be re- 
quired, the special features of which will be determined largely by 
the form and size of the tumor. This will often demand free incisions 
and the extensive removal of such bony structures as may stand in 
the way of free access to the pedicle. When this is reached, the 
separation is easily accomplished by means of the chisel, crushing- 
forceps, or the saw. The only serious accident that may occur, in 
connection with the operation, is excessive hemorrhage, which is for- 
tunately somewhat rare. Occasionally these growths may be removed 
from inside with the snare, if the pedicle can be reached. 



CHAPTER XXXI. 

PAPILLOMA OF THE NASAL PASSAGES. 

Papillomata, or warty growths of the mucous membranes, in 
general would seem to find a predisposing cause in the functional 
movements of the part ; hence the nasal cavity, protected by its bony 
walls, whose functions are carried on in a state of absolute quiescence, 
we should naturally infer, should be to a large extent exempt from this 
form of neoplasm, a fact which clinical observation fully confirms. 
My own records include something over two hundred cases of benign 
tumors of the nose, but one of which was a case of papilloma. 
Schmiegelow found one case in seventeen of nasal tumors, while 
Zuckerkandl found one in thirty -four. On the other hand, Hopmann 
sa,js that he found seventy-eight papillomata in four hundred and 
thirty cases. It is very probable that we have been in the habit of 
overlooking these cases. 

Etiology. — It is not easy to assign any definite cause for the oc- 
currence of this form of neoplasm in the nose. Hopmann gives 
prominence to atrophic rhinitis as exciting their growth. 

Symptomatology. — These growths are attended with no prominent 
subjective symptoms, other than the interference with normal nasal 
respiration. They excite but little irritation, and hence excessive 
discharge does not usually exist. Hemorrhage occasionally occurs, 
probably due to erosion of the mucous membrane, rather than to a 
rupture of blood-vessels in the tumor. Their growth is neither rapid 
nor vigorous, hence, when they even completely fill the nasal cavity, 
they are not capable of producing notable external deformity. Their 
presence, therefore, gives rise simply to the ordinary symptoms which 
attend the development of the softer non-malignant growths. 

Pathology. — According to the usually accepted view, papilloma- 
tous growths of the nasal mucous membrane consist essentially of an 
hypertrophy of all the elements which enter into the formation of the 
normal papillae of the membrane, this hypertrophy involving these 
elements uniformly ; or the greatest activity of the morbid process 
may develop in a single element, such as either the connective tissue 



PAPILLOMA OF THE NASAL PASSAGES. 



235 



or the blood-vessels. Microscopic examination shows each individual 
papilla to be composed of a framework of more or less richly dis- 
tributed connective tissue, containing usually a single vascular loop, 
and the whole covered with epithelial cells. Gland tissue is rarely 
present, and, when present, shows itself in a disorganized or atrophied 
condition. 

At the base of the papillae the glandular elements of the membrane 
show a tendency to proliferation. If we examine a cross-section of 
the papilla, the microscope will show the central blood-vessels sepa- 
rated by the delicate connective-tissue structures, and surrounded by 
a ring, as it were, of epithelial cells. 

According to Hopmann, papillomata of the nose occur in two 
varieties, a hard and soft form. 

Diagnosis. — The small growths, which appear near the margin of 
the nostril, are not unlike warty growths as seen on the integument; 




Fig. 46. —Papilloma of the Nasal Mucous Membrane. (Zuckerkandl.) 

they have a grayish-pink tinge, and mammillated contour. In this 
region the growths are usually of Hopmann' s hard variety, and do 
not ordinarily attain any very great size. When they occur higher up 
in the nasal cavity, they are of a softer consistency, pinker in color, 
and attain a much larger size, while the whole growth is usually 
sessile in character. While the individual papillae may attain con- 
siderable size and present the appearance of an ordinary mucous 



236 DISEASES OF THE NASAL PASSAGES. 

polyp, the whole growth presents an exceedingly irregular surface, 
not unlike perhaps the surface of a raspberry, in which each seed 
follicle projects and becomes to a certain extent pendulous. 

Any doubts in the diagnosis can easily be cleared up by subject- 
ing a portion of the growth to a microscopic examination. They 
seem to be more frequent in females than in males, and belong to 
early adult life, although no age is exempt from them. According to 
Hopmann, the soft variety is much more common, and arises invari- 
ably from the lower turbinated bodies. The hard variety occurs near 
the muco-cutaneous junction, and may spring from the septum, floor, 
or the inner face of the ala. The gross appearance of a small soft 
papilloma is well illustrated in Fig. 46. 

Prognosis. — These growths develop somewhat slowly, and as a 
rule involve no serious danger either to health or to life. 

Treatment. — The soft tumors are to be treated in much the same 
manner as an ordinary nasal polypus ; they are to be extirpated with 
the least injury to healthy structures. I think this is best done by 
the cold snare. The question of cauterizing the base of the growth, 
I think, should be decided entirely by a close observation of each 
individual case, and the recognition of any tendency to recurrence. 
In the small hard variety, situated near the margin of the nostril, the 
growth is easily removed by the cold snare. If the snare cannot be 
used, there is no objection to the use of either the scissors or knife. 
In this variety, it will probably be found best, in most instances, to 
cauterize the base of the growth. For this purpose, perhaps chromic 
acid or acetic acid will give the best results, in that they are the least 
irritating of the chemical agents used for this purpose. Furthermore, 
cauterization will often become necessary to control hemorrhage. 



CHAPTER XXXII. 
ADENOMA OF THE NASAL PASSAGES. 

The nasal mucous membrane does not seem to be a favorable site 
for the development of this form of neoplasm, in that this tissue is 
but scantily endowed with glandular structures. As we have already 
seen, the special function of the glands and follicles in the mucous 
membrane is to furnish it with sufficient moisture to keep it soft and 
pliable. This demand is exceedingly limited in the nasal cavity, 
whose lining is constantly bathed by the serous exosmosis, which 
constitutes the respiratory function of the nose. Hence, with an 
exceedingly small number of glands, whose function is by no means 
active, the tendency to the development of glandular tumors would 
naturally be but very slight, and, in fact, it is a nice question, if, from 
a clinical standpoint, they are ever met with in this region. Gosselin 
has reported two cases as instances of adenoma in the nasal passages. 
We must conclude, however, from the clinical history and pathological 
descriptions given in the reports that they were cases of adeno-sar- 
coma. Pugliese has also described a case in which there was un- 
doubtedly a glandular tumor. In this case, however, the tumor com- 
menced in the lachrymal sac. 

Certainly, until further clinical evidence of the fact has been es* 
tablished, we must conclude that unmixed adenoma does not occur in 
the nasal cavity, and that when glandular tissue is met with in a 
neoplasm it is purely adventitious, and the clinical significance of 
the growth is to be determined by the preponderance of other ele- 
ments, as in adeno-sarcoma, adeno-carcinoma, adeno-fibroma, adeno- 
myxoma, etc. 



CHAPTER XXXIII. 

CYSTOMA OF THE NASAL PASSAGES. 

A cystic tumor involving the mucous membrane in the upper air 
passages probably arises in all cases from the adenoid tissue of the 
membrane, either as the result of degenerative changes, or from re- 
tention of the normal secretion. As we have already seen, morbid 
changes in the glandular structures of the pituitary membrane, from 
a clinical point of view, scarcely ever occur. Hence, we can easily 
understand how a cystic tumor in this region is among the rarest of 
occurrences. 

This form of neoplasm is simple in character and easily dealt 
with, giving rise to no notable subjective symptoms, other than steno- 
sis with catarrhal discharge. It presents no appearances which ren- 
der it easy to distinguish it from ordinary nasal polypus, other than 
the fact that it occurs singly, although perhaps a careful examination 
will reveal the fact of its containing fluid contents. It would seem 
from a clinical standpoint that it is to be treated in much the same 
manner as an ordinary nasal polypus, without requiring the nicer 
manipulation necessary in dealing with myxoma to prevent recur- 
rence. 



CHAPTER XXXIV. 
ANGIOMA OF THE NASAL PASSAGES. 

Considering the highly vascular character of the nasal mucous 
membrane, together with the activity of its functional processes, we 
would naturally suppose it to be a favorable site for the development 
of angiomatous tumors, yet, as a matter of clinical fact, they occur 
very rarely in this region. 

Etiology. — The essential pathological lesion which seems to gov- 
ern the development of this form of neoplasm, does not seem to be 
primarily in a disturbance of the circulation or in any condition 
which leads to a distention of the normal blood-vessels, but it is 
rather to be looked upon as due to some disturbance in the process of 
nutrition in the vascular walls themselves. We are unable to assign 
any definite cause, either active or predisposing, for the development 
of these neoplasms. 

Symptomatology. — The symptoms which arise from the presence 
of these growths in the nose are largely mechanical, nasal respiration 
being interrupted, according to the size of the tumor, while its pres- 
ence also excites a certain amount of muco-purulent discharge. As 
would be naturally inferred, their presence is attended with frequent 
attacks of epistaxis, although this rarely seems to be of a violent 
character, and yet its frequent recurrence may lead to a notable im- 
pairment of the general health. External deformity, dependent on 
any dislocation of the hard parts, is never present. 

Pathology. — This form of tumor is composed almost entirely of 
blood-vessels, held together by a slight network of connective tissue. 
Their mode of development is not known. Their starting-point may 
be in a primary dilatation of the normal vascular structures, or, what 
is more probable, we may have an excessive activity of the normal 
nutritive processes by which normal blood-vessels are formed. This 
process results in the formation of a tumor, in which nutritive activity 
expends itself, as it were, in developing the walls of the blood-vessels, 
leaving no energy for the development of the other elements of the 
tissue. The vascular walls produced in this way are necessarily 



240 DISEASES OF THE NASAL PASSAGES. 

feeble, and possess slight powers of resistance. The course of each 
blood-vessel is marked by dilatation and the formation of even large 
spaces, as it were, scattered throughout the growth. An examination 
of the tissue under the microscope shows a network of wavy connec- 
tive tissue, in some places densely packed together, and in other 
places of exceedingly delicate structure; these bands surrounding 
spaces, as it were, of varying sizes, each space indicating a blood 
course, and yet ordinarily the blood-vessels in their continuity cannot 
be traced. Many of these blood spaces are lined with epithelium, 
while in others this element is entirely absent. The outer surface 
of the tumor shows evidences of the development of a capsule, which 
seems to be of later growth, while above this is a superficial layer of 
the mucous membrane, the gland structures having undergone partial 
or complete degeneration. No portion of the nasal cavity seems ex- 
empt from these growths, but they usually occur rather nearer the 
anterior nares. 

Diagnosis. — These growths usually present appearances sufficiently 
characteristic to make their recognition comparatively easy. Their 
surface is somewhat irregularly rounded, and presents a reddish or 
purplish hue, which indicates unmistakably their highly vascular 
character, a lighter red color indicating usually a larger element of 
arterial blood in the growth. The fluid character of the contents of 
the growth is further evidenced by manipulation with the probe, 
which shows them easily indented. This matter of examination, 
however, should be accomplished with great care, in that they are 
easily punctured by the probe, whereby hemorrhage of an exceedingly 
troublesome character may supervene. If they are within reach of 
the finger, or even by ocular inspection, pulsation of a more or less 
decided character may be recognized. There is probably no growth 
which might lead to an error in diagnosis, unless possibly that of a 
varix springing from the base of the brain. This condition, how- 
ever, would be indicated by the existence of symptoms referable to 
the brain. 

Course and Prognosis. — These growths develop slowly, and run a 
somewhat protracted course, of usually from two to five years. They 
involve generally no danger to life, and are ordinarily amenable to 
surgical treatment, their removal not being attended with any great 
danger, while there is no tendency to recurrence. 

Treatment. — The only danger to be anticipated in the removal of 
these growths lies in the excessive hemorrhage which may attend the 
operation. It is scarcely necessary to say that the forceps never 
should be used. Perhaps no device will accomplish their removal 
more safely than the snare, preferably the cold wire, and it should be 



ANGIOMA OF THE NASAL PASSAGES. 241 

removed very slowly. This is a point on which Jarvis laid special 
emphasis ; he occupied three hours in tightening his loop, and the 
operation was attended with the loss of but a few drops of blood. 
Furthermore, the loop should be adjusted well down upon the pedicle, 
where there is less danger of hemorrhage than in cutting through 
the body of the growth. 
16 



CHAPTER XXXV. 

CHONDKOMA OF THE NASAL PASSAGES. 

The use of this term should be restricted to that large, round, 
nodulated tumor, so very rarely met with in the nose, which presents 
all the clinical characteristics of a fibroma, and yet which, on exami- 
nation, is found to contain hyaline cartilage. 

We can assign no cause for the development of these growths, 
although they seem to belong to the period of adolescence, viz. , from 
eleven to seventeen years of age. When present, they give rise to 
much the same train of symptoms as are met with in fibroma, viz. , 
nasal stenosis, muco-purulent discharge, which may be offensive as 
the result of retention, together with marked external deformity, 
although neither epistaxis nor pain occurs. Their development is 
even slower than that of fibroma. 

They are easily recognized by their exceeding great density, and 
also by their immobility. They are of a yellowish pink color, irregu- 
larly nodulated surface, and present a hard cartilaginous sensation to 
the touch. They can be readily distinguished from an osteoma by 
means of the needle, although they may easily be confused with a 
fibroma, recognition being made only by an examination of a portion 
of the growth, after removal. They are usually not larger than a 
grain of corn, but may attain sufficient size to seriously impede re- 
spiration. They are ordinarily situated at the junction of the carti- 
laginous septum with one of the alar cartilages, that is, at the anterior 
inferior angle of the cartilaginous septum. 

The prognosis is usually good, in that the growth appears to be 
quite amenable to surgical interference, either by an external operation 
or the cold snare. 



CHAPTER XXXVI. 

SAKCOMA OF THE NASAL PASSAGES. 

Under the general term of cancer, formerly, were embraced all 
forms of malignant tumors, carcinomata as well as what are now 
termed sarcomata. A distinction has been made, in our day, between 
carcinoma and sarcoma; both are considered malignant growths, but 
they differ in a marked degree, not only in their course and clinical 
history, but also in their prognosis. Sarcoma is by no means fre- 
quently met with in the nasal passages, and its literature is somewhat 
limited. 

Etiology. — As regards the etiology of this affection, but little is 
known. It is possible that a spontaneous conversion of myxoma into 
sarcoma may occur. 

It is perhaps true that catarrhal inflammation of the nose may 
predispose to sarcoma. 

A very noticeable feature of sarcoma of the nose is the age at which 
it seems to develop. According to my experience, while there were 
a few instances in elderly people, the very large proportion of them 
occurred earlier than the age of forty, the average being something 
less than thirty-nine, differing in this respect, in a very marked de- 
gree, from the clinical history of cancer, which develops, as a rule, 
late in life. It was also noticed that sarcoma seemed to run a some- 
what slow course when it developed in the nose. 

Pathology. — The structure of sarcoma of the nose differs in no 
essential respect from the same morbid process as developed in other 
portions of the body, except in so far as it is modified by the special 
tissue from which it develops. It must be borne in mind that the 
normal membrane of the nose is exceedingly rich in lymphoid tissue, 
which oftentimes bears a somewhat confusing resemblance to the 
structure of round-celled sarcoma. 

The surface of the growth is sometimes covered with flattened 
epithelium, due to the mechanical pressure upon the normal columnar 
epithelium. 

Symptomatology. — The prominent symptom of the presence of a 



244 DISEASES OF THE NASAL PASSAGES. 

sarcomatous growth, as of every nasal tumor, is in the obstruction of 
nasal respiration. Coincident, however, with this symptom, in the 
large majority of cases, occurs epistaxis, of a more or less violent 
character. This symptom seems to be strikingly characteristic of sar- 
coma, as also of fibroid. 

The discharge from the nose is of a sero-sanguinolent character, 
and usually gives rise to quite an offensive odor. The fetor is un- 
doubtedly due to retention of secretion, with decomposition of its 
organic constituents. 

Deformity of the nose depends on the size and consistency of the 
growth. 

Diagnosis. — The gross appearance of the growth presenting in the 
nasal cavity is a bluish-gray surface, with a soft flabby consistency, 
which should in all cases excite suspicion of the existence of a malig- 
nant disease, especially in connection with the repeated hemorrhages 
which so frequently occur in these cases. The diagnosis, however, 
will always depend upon the microscopic examination of a portion of 
the growth. Furthermore, impact upon the growth with a probe 
will show it to be, to a certain extent, movable in the nasal cavity, 
as the tumors are invariably pedunculated. They spring with about 
equal frequency from both the outer and the inner wall of the cavity, 
and usually occur as a single tumor. 

Prognosis. — An analysis of the cases reported, would seem to in- 
dicate that in about half of them the patients recovered, and yet I am 
disposed to think that the prognosis is not so favorable, as our knowl- 
edge of the subsequent history is not sufficiently definite to warrant us 
in the conclusion that the disease was eradicated. Yet sarcoma in the 
nose apparently does not present the same malignant tendencies as it 
does when found in other localities. In many instances, its progress 
is extremely slow, and apparently is arrested with ease. Age seems to 
exercise a certain amount of influence on the prognosis of these cases, 
in that in advanced life the disease is less amenable to operative inter- 
ference than in youth. Aside from these considerations, our progno- 
sis must be based on the extent of the disease, its duration, and es- 
pecially on its apparent rapidity of growth. The character of the 
growth has an important bearing on the prognosis, in that a round- 
cell sarcoma is to be regarded as more malignant in its tendencies 
than the other varieties. In those cases in which we find the sarco- 
matous elements intermingled with the normal tissue elements the 
prognosis is rendered less grave. 

Treatment. — There are no local applications which have the 
slightest effect on a sarcomatous tumor in the nose. The only treat- 
ment is the thorough and complete eradication of the growth, and 



SARCOMA OF THE NASAL PASSAGES. 245 

this at the earliest period possible, without regard to the character 
of the tissue. If there is a marked hemorrhagic disposition, as in the 
angiomatous tumors, the operation should be proceeded with as 
rapidly as possible, without regard to the hemorrhage, as this com- 
plication can be controlled when its arrest becomes necessary. Fur- 
thermore, I think, ordinarily the growth should be removed through 
the natural passages when it is feasible, although, if better access to 
the nasal cavities is demanded, an operation on the external nose does 
not necessarily complicate the final result. The growth may be extir- 
pated by the curette, spoon, the cold snare, or the galvano-cautery 
loop. Probably the cold-wire loop, properly manipulated, affords 
the best method of removing the small tumors, and the larger growths, 
even, may be removed piecemeal by this method. This manipula- 
tion, certainly, is easier of accomplishment than the application of 
the galvano-cautery loop ; and furthermore, I think it is a nice ques- 
tion, oftentimes, whether the galvano-cautery should be used, as I am 
convinced, from my own personal experience, that it may stimulate a 
sarcomatous tumor to renewed activity of growth. The most serious 
obstacle met with in these operations is always the excessive hemor- 
rhage. The source of the hemorrhage is always the tumor itself, 
and the indications are to get the growth out as rapidly as possible 
and to get down to its attachments. When this part is reached, the 
hemorrhage, as a rule, ceases at once. In a rapid operation, then, 
either bimanual manipulation, by means of one finger in the nostril 
and one in the nares, will be resorted to, or the curette will be used 
through the nostril, its manipulation being aided by the finger in the 
posterior nares. In order to facilitate this manipulation, an incision 
may be made through the soft palate. In operating in this way it is 
necessary that the mouth should be held open by a mouth gag, while 
an assistant stands ready to prevent the blood from flowing down into 
the larynx and trachea, although in many cases the choanse are suffi- 
ciently plugged by the growth itself, until the posterior attachments 
are thoroughly severed, after which, by tilting the head forward, the 
blood makes its escape from the anterior nares. After the growth 
has been removed, the subsequent hemorrhage is easily controlled 
by packing the nose with one or more small sponges. 

The primary operation on these growths I regard as but the com- 
mencement of treatment, the more important part being the subse- 
quent close watching of the cavity, to arrest and control any tendency 
to a reappearance of the growth. 

As regards the advisability of cauterizing the base of the tumor, 
by means of the galvano-cautery or some one of the various chemical 
agents, I think this is oftentimes not only uncalled for, but mischie- 



246 DISEASES OF THE NASAL PASSAGES. 

vous, while in other cases their use would seem to be attended with 
the best results. The only indication here, then, will be that any 
caustic agent for the control of sarcomatous recurrence, must be used 
with the greatest possible care, and its immediate effect watched. 

The first stage of chloroform anaesthesia is quite sufficient for the 
primary operation. "When the growth is smaller, local anaesthesia 
with cocaine is all that will be required. 



CHAPTER XXXVII. 

CAKCINOMA OF THE NASAL PASSAGES. 

It would seem that there is nothing in the morbid process consti- 
tuting catarrhal inflammation which favors the development of malig- 
nant disease, for, while inflammatory action of the nasal mucous mem- 
brane is one of the most frequent affections, I think Grynfeldt's view 
must be accepted, that a malignant disease in this region is one of 
the rarest conditions. That it should be so rare is probably due in 
some degree to the fact that the nasal mucous membrane, inclosed 
within its bony walls, is so thoroughly protected from any con- 
stantly acting traumatic or directly irritating influences. That car- 
cinoma may have its primary origin in the nasal cavity, however, 
cannot be questioned, in face of testimony given by many authorities. 

Etiology. — It is a very easy matter, after malignant disease has 
developed, to trace its origin back to some injury received in previous 
years, and yet to connect the injury in a direct positive relation with 
the development of the cancer is by no means so easy a matter. 
Hence, when we say that a cancer may be due to traumatism, it is a 
suggestion not clearly warranted by clinical observation. Heredity 
is the one powerful predisposing cause of the disease. Aside from 
this consideration, I do not think we know why malignant disease 
occurs. 

The question of the transformation of a benign into a malignant 
growth has already been discussed in the chapter on nasal polypi. A 
certain amount of clinical evidence seems to show that a nasal polyp 
may be transformed into a sarcoma, when subjected to unwarrantably 
harsh interference, yet there is no ground for supposing that a car- 
cinomatous transformation ever takes place. 

As regards the age at which the disease develops, cancerous de- 
posits in the nose follow the same course as in other parts of the body, 
occurring, as a rule, after middle life, with very rare exceptions which 
have occurred in childhood. 

Pathology. — Carcinoma of the nose, from a pathological point of 



248 DISEASES OF THE NASAL PASSAGES 

view, presents no characteristics which differ from the same form of 
tumor in other portions of the body. Hence a full description of the 
minute pathology of these growths need not be given here. 

Symptomatology. — The character of this disease is specially sug- 
gested by the occurrence of a peculiar sero-sanguinolent acrid dis- 
charge. Epistaxis occurs in a certain proportion of cases, but per- 
haps not so frequently as is the case with sarcoma of the nose. Pain, 
which is usually so prominent a symptom of the development of can- 
cer elsewhere, does not seem to be characteristic of the disease when 
met with in the nasal passages. Nasal stenosis, with deformity of 
the external nose, of course, is present, according to the duration and 
extent of the disease. As the tumor invades the sphenoid and 
ethmoid cells, we have the symptoms characteristic of disease in these 
cavities, such as exophthalmos, impairment of vision, etc. 

Enlargement of the lymphatic glands does not seem to be a fre- 
quent concomitant of the disease, although occasionally noted. Mai- 
sonneuve does not find the submaxillary glands enlarged unless the 
antrum is involved, with infiltration of the skin in the infra-orbital 
region. 

In cases reported by Earle and by Watson secondary carcinoma- 
tous deposits were found in certain of the viscera on autopsy, although 
hot giving rise to any symptoms which led to their recognition before 
death. 

Diagnosis. — With our present methods of examining the nasal 
cavities, a growth should always be recognized very early in its de- 
velopment, when a small portion can be removed for examination with 
the microscope, which will reveal its character. This removal should 
in all cases be accomplished by means of the cold-wire snare, as 
avoiding any unnecessary harshness in manipulating the growth, 
whereby a renewed activity of development might be stimulated. In 
sarcoma secondary enlargement of the cervical glands is never present. 
In carcinoma, however, this symptom seems to be present in a few 
cases. Ulceration of the surface of carcinomatous tumors is more 
frequently met with than in sarcomatous growths, and hence the 
former are more liable to be the seat of hemorrhages. 

Peognosis. — The prognosis of carcinomatous deposits in the nasal 
passages is essentially grave. In cancer, in general, we usually ac- 
cept the view that the average duration of life is three years. From 
a review of numerous cases, however, it would seem that the progno- 
sis in carcinoma of the nasal passages is more unfavorable, the dura- 
tion of life in many instances being only twelve months. Further- 
more, the time of life seems to have a certain influence, as it would 
appear that when the disease develops late in life it runs a very 



CARCINOMA OF THE NASAL PASSAGES. 249 

rapid course. The character of the tumor does not seem to modify 
the prognosis in any marked way. 

The cases which have been reported as cured were all undoubtedly 
instances of cylindroma, a form of tumor which seems to be some- 
what vaguely classified by pathologists, and which, while presenting 
certain histological evidences of malignancy, from a clinical point of 
view manifests but very slight malignant tendencies, and perhaps, 
therefore, should not be regarded as a malignant disease. The prog- 
nosis in cylindroma as to the successful arrest of the disease, if rec- 
ognized sufficiently early, and before the disease has invaded inacces- 
sible parts, such as the sphenoid or ethmoid cells, is to be regarded 
as favorable. The cause of death, in most of these cases, is exhaus- 
tion, unless death follows immediately upon an operation. The 
malignant process, having its origin in the nasal cavity proper, suc- 
cessively invades the accessory sinuses, and, in still rarer cases, the 
cranial cavity. 

Treatment. — If the microscopic examination shows that the dis- 
ease consists of cylindroma, treatment may be undertaken with every 
"promise of success ; but in all cases, harsh or irritating measures, 
whereby a greater malignancy of growth might be developed, should be 
avoided. Hence, in these cases, the growth should be removed, pre- 
ferably by means of a cold snare, and possibly the curette, and the 
base cauterized, perhaps, but the caustic applied with great care, and 
somewhat sparingly, the action of the agent being closely observed. 
When the growth has obtained considerable size, a more radical and 
rapid operation becomes necessary. If we have to do with carcinoma, 
it becomes a nice question how far life may be prolonged by the 
radical operation. I know of no well-authenticated case of the suc- 
cessful removal of a carcinoma of the nose, through the natural pas- 
sages. In the majority of instances, the growth has its origin in the 
upper and narrower portion of the nose, in close proximity to the 
superior turbinated bones ; hence, even when early recognized, it has 
invaded regions almost inaccessible by the simpler manipulations. 
Of course, if the growth is small and within reach, it becomes our 
duty to remove it in this manner if possible. The results reported in 
cases operated upon offer a most discouraging outlook, as in all but 
four of them surgical interference shortened rather than prolonged 
life. 



CHAPTER XXXVIII. 

DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 

Under this consideration is included a study of the diseased con- 
ditions which involve the cavities found in certain of the bones of the 
face and skull, which communicate with the nasal passages by one or 
more small openings. These cavities are : the antra of Highmore, or 
the maxillary sinuses ; the ethmoidal, the sphenoidal, and the frontal 
sinuses. 

Disease of the Antrum. 

This term is used to designate a not infrequent complication or 
concomitant of catarrhal inflammation of the nasal mucous mem- 
brane, which is characterized by an inflammatory process in the 
mucous membrane lining the antrum of Highmore, which subsequent- 
ly degenerates into the purulent process. This pus secretion, accu- 
mulating in the cavity of the antrum, makes its exit through the ostium 
maxillare, and escapes into the nasal cavity, giving rise to a more or 
less profuse pus discharge from the nose. 

Etiology. — Zuckerkandl takes the ground that the most frequent 
cause of the disease lies in an extension of the inflammatory process 
from the nasal cavity, a view also entertained by Schiffers, Chatellier, 
and Krause. In a previous chapter, this question of extension of 
catarrhal inflammation has been discussed somewhat at length, and 
the ground taken that catarrhal inflammation shows a notable hesi- 
tancy in extending from one anatomical region to another. A 
catarrhal inflammation of the nose is the result of local conditions 
which do not, in any degree probably, operate in the maxillary si- 
nuses. In other words, so-called nasal catarrh is a perversion of 
function of the normal respiratory apparatus of the nose, and its 
causes operate on those tissues only and would have no effect on the 
delicate membrane lining the antrum. Hence, I think it is an exceed- 
ingly rare event that disease of this cavity results by an extension of 
inflammation through continuity of tissue. This view is notably 
strengthened when we consider the large number of individuals who 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 251 

suffer from chronic rhinitis, and. the very small proportion of these 
in which antral disease occurs. That hypertrophic rhinitis is the 
cause of the disease, in a large number of cases, is undoubtedly true — 
not by extension, however, but because the hypertrophic process de- 
velops in such a manner as to produce stenosis or complete occlusion 
of the ostium maxillare. Furthermore, as we know, this orifice varies 
greatly in different individuals. Quite extensive hypertrophy in one 
case might fail to produce any notable stenosis, while in others a 
moderate degree of thickening of the membrane might produce com- 
plete obstruction. The closure of this orifice would naturally act, in 
the first place, to produce moderate liypersemia of the mucous mem- 
brane lining the sinus, resulting necessarily in a certain increase of 
secretion. In health this membrane secretes just sufficient mucus 
to keep its own surface moistened and no more. Another element 
enters into this consideration, as pointed out by Zuckerkandl, in that 
in a patulous condition of the ostium maxillare no considerable 
amount of moisture is dissipated by evaporation; hence, we can 
readily perceive that when this orifice is closed there would neces- 
sarily be an accumulation of secretion, even were the membrane in a 
healthy state. Add to this, liypersemia, with hypersecretions in the 
lining membrane, and it would become apparent how the secretion 
must accumulate in the sinus. The necessary result of this is a 
catarrhal inflammation, which eventually degenerates into one charac- 
terized by a purulent discharge, for I regard it as an invariable rule 
that a catarrhal secretion in a closed cavity must give rise, sooner or 
later, to a purulent discharge. 

It is a very ancient tradition that decayed teeth are a frequent 
source of purulent disease of the antrum. When we consider that the 
first and second molar teeth usually project into the floor of the cav- 
ity, and occasionally penetrate it (see Fig. 47), we can easily under- 
stand how caries of these teeth might act to produce suppuration in 
the cavity. That carious teeth are a frequent source of the disease, 
cannot be questioned ; that they are the most frequent, is probably 
not easy to decide. From my own point of view, I should say not, 
and yet we can easily understand why this has been asserted broadly 
and with emphasis by an oral surgeon, since cases due to carious 
teeth, as a rule, fall into the hands of the dentist or oral surgeon, 
while those cases dependent on other causes naturally fall into the 
hands of the throat specialist. Watson states that nasal polypi may 
produce the disease, a cause not usually mentioned by other writers, 
and yet I regard this as one of the most frequent sources of suppu- 
rative inflammation of the antrum. This, it seems to me, can easily 
be understood when we consider the fact that mucous polypi have 



252 



DISEASES OF THE NASAL PASSAGES. 



their origin, in the large majority of cases, in the immediate region 
of the ostium maxillare, and very early in their development act to 
produce occlusion of this orifice. I am disposed to think that, in 
many cases, the involvement of the antrum is overlooked, in the 
somewhat more prominent symptoms to which polypi give rise, and, 
furthermore, that its purulent discharge, becoming mingled with and 
diluted, as it were, by the sero-mucous discharge effected by the 
polypus, fails of recognition as a distinct pus secretion. Certainly 
in those cases in which the polypi have developed to the extent of 
completely filling the nasal cavity, producing complete stenosis, I 




Fig. 47.— Transverse Section of the Maxillary Sinuses, showing the Roots of the Molar Teeth pro- 
truding into the Cavities through the Floor. (Zuckerkandl.) 



think it is almost the exception that the maxillary sinus does not 
become the seat of a suppurative inflammation. This complication, 
however, becomes evident only after the nasal passages have been 
thoroughly cleared of the polypi. I am disposed to regard this, 
then, as perhaps the most frequent cause, hypertrophic rhinitis next, 
and, least frequently, carious teeth. In the same manner, an attack 
of acute rhinitis is not infrequently attended with symptoms referable 
to the maxillary sinus, and hence may be an exciting cause of sup- 
purative disease of that cavity. That this accident is not of more 
frequent occurrence is probably due to the fact that the acute rhinitis 



DISEASES OF THE ACCESSORY SIXUSES OF THE XOSE. 253 

subsides in natural course, before mischief of a sufficiently permanent 
character has been done to the membrane lining the antrum to lead 
to the development of the chronic lesion. The same may be said of 
croupous and diphtheritic inflammation of the nasal cavity. Further- 
more, it should be mentioned that Zuckerkandl has stated that the 
mucous membrane lining the antrum does not present the anatomical 
characteristics which favor the development of a fibrinous exudation, 
and hence an inflammation of this membrane would be of a simple 
catarrhal character, even in the event of its being excited by the 
croupous or diphtheritic lesion in the nose. 

Among the somewhat rare causes of the disease may be mentioned 
traumatism. Cases have been cited as resulting from an accident 
attendant upon parturition, from Malgaigne's operation for division 
of the infra-orbital nerve, and from an attack of facial erysipelas. 

I believe it to be purely a local disease, and due to local causes, 
although Watson makes the broad statement that the general health 
is almost always at fault. 

Pathology. — At the onset of the affection, the mucous membrane 
is hypersemic, slightly swollen, and with its surface dotted over with 
minute points of ecchymosis, due to the fact that the blood-vessels 
coursing through the membrane possess exceedingly thin, delicate 
walls which rupture easily, giving rise to slight localized hemor- 
rhages. As the disease progresses, the membrane becomes swollen to 
ten or fifteen times its normal thickness, this swelling being largely 
due to an cedematous condition, which presents somewhat irregu- 
larly, giving rise to small localized tumefactions, producing a some- 
what mammillated contour. This infiltration involves not only the 
superficial, but the deep layer of the menibrane, which in this region 
constitutes the periosteum of the bony walls of the sinuses. In con- 
nection with this there is a somewhat profuse serous exudation, 
under which the blood-vessels unload themselves, and the swollen 
membrane to an extent subsides, followed by a more or less profuse 
secretion of sero-mucus, together with blood, and this in the course 
of time, occupying weeks or perhaps months, results finally in a dis- 
charge of pure, laudable pus. The later stages of the disease are 
characterized by a certain activity in the deep layers of the membrane 
or periosteum, under which there are formed lamellae or spiculae of 
new bone, which may project into the cavity, or may form thin plates, 
crossing it in such a way as to divide it into two or more small cham- 
bers. This perversion of fuuction may go so far as to lead to the 
formation of small bony tumors within the cavity, entirely separated 
from its walls. This process is probably closely allied to calcareous 
degeneration of the mucous membrane. 



254 DISEASES OF THE NASAL PASSAGES. 

Symptomatology. — At the onset of the disease, if the cavity be- 
comes filled with serum or sero-mucus, whose exit is prevented by an 
obstruction of the ostium maxillare, pain referable to the region be- 
comes a prominent symptom, together with a sense of fulness and 
weight below the orbit. Unless relief is soon given, this pain may 
become of a most agonizing character, extending over the whole side 
of the face. The pain over the cheek bone involves the upper teeth, 
which give the impression of being elongated, and crowded out of 
their sockets, mastication thus becoming painful. In connection with 
the facial neuralgia, there is liable to be more or less general hyper- 
esthesia of the face, with tenderness on pressure over the trunks of 
the nerves, as they emerge from the foramina. This sense of fulness 
may also be felt in the roof of the mouth, which may be crowded 
downward from up above and bulged into the oral cavity. Schech 
states that protrusion of the eyeball, with atrophy of the optic nerve, 
may occur in connection with antrum disease; while Ziem has re- 
ported a case of purulent disease of the antrum, in which the affec- 
tion had caused narrowing of the field of vision, which disappeared as 
soon as the pus was evacuated from the maxillary sinus. These 
symptoms, however, would rather indicate disease of the ethmoidal 
or possibly the sphenoidal sinuses. These sensations may persist 
for several days, and are relieved spontaneously, or at the hands of 
the surgeon. If spontaneous relief occurs, it is usually with a profuse 
discharge of ill-smelling pus from the nasal cavity of the side affected, 
mixed with a certain amount of minute blood clots. The escape of 
pus may be either through the normal opening, or by an artificial 
opening through the thin lateral wall of the cavity, and, in still rarer 
cases, the spontaneous evacuation may take place through the alve- 
olus, cheek, or orbit. Among the rarer events is the extension of the 
disease to neighboring cavities. Thus, in a case reported by Maier, 
even after opening the antrum through the alveolus, the disease in- 
vaded successively the ethmoidal sinuses, the orbit, and the cephalic 
cavities, resulting in meningitis and death. 

After this spontaneous evacuation of the cavity, the pus discharge 
continues, for, it may be, a lengthened period of time, flowing freely 
from the nasal passage, when obstruction again occurs, and with its 
attendant symptoms of pain and sense of fulness about the maxillary 
region; these symptoms, however, being not so well marked, as a 
rule, as in the case of a primary attack, the further progress of the 
disease being characterized by these intermittent attacks of retention. 
In most cases, perhaps, the disease is chronic from the onset, the os- 
tium maxillare remaining patulous, and the course of the disease 
never being marked by an attack of pus retention. When this occurs, 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 255 

the prominent symptom is a discharge, from one nasal cavity, of a more 
or less profuse purulent secretion, which shows a certain amount of 
diurnal intermittence. On waking in the morning, a large amount 
which has accumulated over night is discharged, while through the 
day the evacuations are in smaller quantities, the patient soiling per- 
haps three or four handkerchiefs, the pus being of a bright yellow 
color, and emitting no marked odor, except, perhaps, with the first dis- 
charge in the morning. In connection with this, neuralgic pains of 
a mild character, referable to the side of the face affected, are often 
noticed, which occasionally extend also to the teeth. In the late stages 
of this form of the disease, the teeth whose roots project into the floor 
of the antrum may become carious as the result of periostitis and 
necrosis involving the thin bony plates covering them. 

This would suggest that the carious teeth, which in many cases 
are said to be the cause of the antrum disease, may rather be the 
effect of it. Although there may be no obstruction to the escape of 
the pus, the cavity is probably most of the time full, up to the level 
of the opening, hence in many cases, as the result of the thinning of 
the anterior wall, which may become almost parchment-like, a slight 
bulging, with fluctuation, may be observed over the canine fossa. As 
the purulent secretion passes into the nasal cavity, it retains its 
fluidity, and is expelled in the same condition. Crust formation is 
never a feature of this disease, nor is the mucous membrane of the 
nose in any way affected by the presence of the pus. Cough may be 
a prominent symptom, due to the purulent secretion making its way 
into the pharynx and upper air passages, as it occasionally does, es- 
pecially on waking in the morning, and in that way becoming an 
exceedingly disagreeable and oftentimes a distressing symptom. In 
the same manner, I should attribute any symptoms referable to the 
upper air tract to a concurrent disease of the nasal mucous membrane, 
rather than to direct influence of the antral affection. 

Diagnosis. — A pus discharge from but one nasal cavity should 
always excite suspicion of the existence of suppurative disease of one 
of the accessory sinuses. The only affections which give rise to a 
unilateral pus discharge from the nose are foreign bodies, syphilis, 
and neoplasms, in all of which the accompanying symptoms are so 
prominent that a differential diagnosis should never be difficult. The 
character of the pus discharge in antrum disease, in all cases proba- 
bly, is that of a uniformly bright yellow, cleanly secretion, and the odor 
is somewhat characteristic, being that of sulphuretted hydrogen, and 
never presenting the intolerable fetor characteristic of syphilis, or the 
musty graveyard odor of oza?na. Furthermore, the odor is present 
only when pus is evacuated after being retained for a day or longer. 



256 DISEASES OF THE NASAL PASSAGES. 

In making an examination of the nasal cavity, a four-per-cent so- 
lution of cocaine should first be applied, to contract the tissues, after 
which, on ocular inspection, there will be found a small mass of 
bright yellow, canary-colored, or perhaps straw-colored pus, lying on 
the lower border of the middle turbinated bone, about midway of its 
course. If the discharge in the nose is free, the secretion will be 
found coating the lower turbinated body, and possibly lying upon the 
floor of the nares. If, however, this be wiped away with a pledget 
of cotton, the origin of the pus will easily be detected, as oozing from 
beneath the middle turbinated body. If, furthermore, a probe 
wrapped with a small pledget of cotton be pressed up against the 
point from which the pus apparently issues, the manipulation will be 
followed by a flow of pus directly from the cavity, which now will 
emit, if the pus discharge is free, the characteristic odor of fetid hy- 
drogen. The question of differential diagnosis now arises, to deter- 
mine from which of the accessory sinuses the pus issues, and this in- 
volves some exceedingly nice questions, which are not always easily 
decided. The best procedure is to direct the patient to lie down on 
the unaffected side, a position in which discharge from the antrum 
would be facilitated, while there would be little or no tendency to the 
escape of pus from any of the other sinuses ; hence, keeping in this 
position for ten minutes or longer, especially if the erect position had 
been maintained for several hours beforehand, the exit of pus from 
the maxillary sinus would be obtained, if suppurative disease existed 
there. Percussion of the two sides should always be resorted to, for 
by this means we may detect a dulness over the affected side, as well 
as a certain amount of sensitiveness. Watson suggests tapping the 
teeth of the upper jaw successively, and, if tenderness be discovered, 
that the pulp-chamber should be examined with reference to a diseased 
condition. Tenderness on pressure over the canine fossa, or above 
the alveolar process in the oral cavity, may constitute a symptom of 
some diagnostic value, although it is not usually present. Puncture 
of the antrum by means of an exploring needle, or with the aspirator, 
is a comparatively simple test, against which there lies no objection, 
other than the damage of breaking the needle if the bone be thick or 
dense. This exploration should preferably be made through the outer 
wall of the antrum, an incision being made through the gingivo-labial 
fold, above the second molar tooth. Schmidt advises that such an 
exploratory puncture be made in doubtful cases, by means of a strong, 
curved aspirating-needle, piercing the internal wall of the antrum, in 
the inferior meatus of the nose. If either the first or second molar 
tooth is carious, it should be extracted, and access to the cavity for 
exploratory purposes is easily obtained through the alveolar process, 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 257 

although I question the propriety of extracting a sound tooth for this 
purpose, considering the ease with which the cavity may be entered 
at the points above mentioned. At best, the diagnosis of these cases 
is oftentimes quite obscure, and can be obtained only by exclusion 
and a careful study of symptoms, the only absolute diagnostic sign 
being gained by access to the cavity. 

Prognosis. — These cases rarely involve any danger to life, unless, 
as may happen, the disease extends to the sphenoidal and ethmoidal 
sinuses, and yet their diagnosis and treatment occasionally present 
difficulties, which, although not insurmountable, oftentimes tax the 
therapeutic resources of the surgeon and weary the patience of the 
sufferers. Garretson states with a considerable degree of emphasis 
that " diseases of the antrum are for the most part simple in char- 
acter, easy of diagnosis, and as a rule not at all difficult of treat- 
ment." This is the point of view of the oral surgeon, whose cases 
are mainly dependent on carious teeth, and which, therefore, yield 
reauily to treatment, by the simple measure of removing the cause, 
when oftentimes a cure ensues without further treatment. Cases 
which result from intranasal disorders or traumatism yield less 
readily, and often require a somewhat prolonged course of treatment. 
Spontaneous resolution of chronic suppurative disease of the antrum 
probably never occurs. In an acute catarrhal attack from an acute 
rhinitis, spontaneous resolution is perhaps the rule. 

Treatment. — The essential feature of the treatment of a case of 
suppurative disease of the antrum consists in opening the cavity for 
proper drainage, and subsequently its thorough cleansing and disin- 
fection. If it occurs in connection with nasal polpyi, hypertrophic 
rhinitis, deformity of the septum, or other obstructive lesion, I think 
it is important that these lesions should be removed as far as possible, 
by a proper mode of treatment, before further measures are resorted 
to. The removal of the nasal obstruction offers the hope that the 
normal orifice of the cavity may be found patulous, in which case a 
freer drainage will be afforded. In addition to this, disinfecting 
lotions should be used by the patient several times daily, to prevent 
the ostium from becoming blocked by accumulated secretions. For 
this purpose there may be used a solution of carbolic acid, three 
grains to the ounce, boric acid, twenty grains to the ounce, to which 
may be added bicarbonate or biborate of soda in the proportion of five 
grains to the ounce. This can be used by means of the small atom- 
izer (see Fig. 18). After the thorough cleansing of the parts, I have 
seen excellent results from the use of the following, as a spray : 

B; Terebene 3 ss. 

01. petrolati (zero) , § i. 

17 



258 DISEASES OF THE NASAL PASSAGES. 

This process, however, involves a long and somewhat tedious 
course of treatment, with exceedingly doubtful results, for, in remov- 
ing the cause of the disease, it is questionable whether we succeed in 
even modifying the morbid process which has fixed itself upon the 
mucous membrane lining the cavity, and furthermore it is not prob- 
able that fluids injected into the nasal cavity reach to any extent the 
diseased sinus. We not only require penetration of the cavity, but 
its thorough cleansing. Wolfram reports a case of antrum disease of 
six months' standing, cured by the use of the steam atomizer, from 
which, after the parts were cleansed with the nasal douche, a two-per- 
cent solution of tannin and glycerin was inhaled twice daily, and 
subsequently acetate of alum, a cure being effected in a few weeks. 
Storck treats his cases by local medication through the nose. The 
nozzle of a syringe is inserted directly into the antral orifice, in those 
cases in which this is feasible. When this cannot be seen, he uses a 
syringe with a straight nozzle, the distal opening of which is closed, 
and the side perforated. Now, by moving this along the middle 
meatus, he claims that when the jet enters the antrum the patient 
is conscious of it, and in this way the location of the opening is as- 
certained, and its distance from the margin of the nostril recorded 
by a mark on the tube of the syringe. In order to gain freer access 
to the parts, he states that the nasal passages may be dilated by 
packing them with pledgets of cotton, previous to the use of the 
syringe. I know of but one way to dilate the nasal cavity, and that 
is to contract the tissues by the application of cocaine, as in all forms 
of mechanical dilatation the stenosis recurs by the return of the blood 
flow, immediately after the removal of the dilator. 

In a large proportion of cases, a successful cure of disease of the 
maxillary sinus requires that an artificial opening be made. If the first 
or second molar tooth is carious, or loosened, there can be no question 
that the access to the cavity is better obtained by its removal. In 
some cases this procedure will reveal the existence of an opening, 
while in others, it will be necessary to drill upward through the tooth 
cavity, until the antrum is reached. The penetration of the sinus 
should be followed by an escape of pus. We thus have established 
two openings into the cavity, one of which, being situated in its most 
dependent portion, presents the conditions essential for its proper 
drainage. The indications now are the thorough cleansing of the 
diseased part, while at the same time a patulous condition of the ar- 
tificial opening is maintained. Cleansing is accomplished by syring- 
ing through the artificial opening daily, until the solution escapes 
through the nasal orifice. The fluids adapted to this are any of those 
already mentioned. After the cavity is thoroughly cleansed, there 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 



259 



should be injected a mild and unirritating astringent, such as sulpho- 
carbolate of zinc, five grains to the ounce ; resorcin, five grains to the 
ounce ; hydro-naphthol, half a grain to the ounce ; nitrate of silver, five 
grains to the ounce, etc. Tincture of iodine may be used in the strength 
of fifteen minims to the ounce of water. To prevent a closure of the 



© 



Fig. 48.— Silver Drainage Tube for the Antrum, full size. 

artificial opening, it will be necessary to insert a drainage tube (see 
Fig. 48) . The best form of this is a silver tube three-fourths to one inch 
long, and one-eighth of an inch in diameter, which should be provided 
with a collar or flange, by means of which it is attached, by a silk 
thread, to a neighboring tooth. Salter suggests that a vulcanite plate 
be made to fit the gum, into which the drainage tube is inserted, of just 
sufficient length to reach the orifice. The lower end of the drainage 
tube is so constructed as accurately to fit the nozzle of the syringe, 
which is used for injecting into the cavity. In case the patient wears 
artificial teeth, any dental surgeon can easily attach a small piece to 
the plate, which, pressing against the flange of the tube, will hold it in 
place. Any small syringe, fitted with a proper nozzle, is adapted for 
use in these cases. I usually direct the patient to provide himself 
with an ordinary dental syringe, or an Anel's lachrymal syringe (Tig. 
49) ; with this the cavity is to be cleansed at least twice daily. In 




Fig. 49.— Anel's Lachrymal Syringe, for use in Disease of the Antrum. 



some instances patients have acquired the habit of cleansing the cavity 
without the use of a syringe, simply filling the mouth with a solution 
of salt water, or some other simple lotion, and forcing it through the 
tube by the lips, cheeks, and tongue, the head being held over a 
proper receptacle, into which the lotion falls from the nose. The re- 
tention of the tube must be continued according to the duration of the 
pus discharge. In one case of Bordenave's, a cure was effected and 



260 DISEASES OF THE NASAL PASSAGES. 

the tube removed at the end of two months, while in another it was 
retained for two years before it could be removed with safety. 

When the cavity is first opened, it is important that it should be 
thoroughly explored by means of the probe, in order to detect the ex- 
istence of necrosed bone, or other unusual conditions, as in one case, 
a supernumerary tooth was the source of the suppuration, while in a 
case cited by Giraldes local medication failed to arrest the suppura- 
tive process, until a bony septum traversing the cavity was dis- 
covered and broken up by means of a probe. In those cases in 
which no evidence of diseased teeth is discovered, the question 
arises as to the propriety of sacrificing a sound tooth. The only 
advantage of this lies in the fact that we thereby establish an arti- 
ficial opening in the most favorable position for securing drainage, 
viz., in the dependent portion of the cavity. I do not think the ad- 
vantage of this opening is sufficient to warrant the sacrifice of a sound 
tooth, when we consider the simplicity and efficacy of the operation 
first suggested by Mickulicz of opening into the antrum through the 
inferior meatus. This is done by an instrument which consists of a 
spear-pointed knife, mounted on a shaft, curved to a right angle, and 
fitted with a shoulder, about three-eighths of an inch from the point, 
in such a manner as to regulate the depth of the cut. The instrument 
being carried within the nostril, the incision is made at a point in the 
lower meatus, immediately below the normal orifice of the antrum, 
the direction of the incision being upward, backward, and outward, in 
order to avoid the hard, bony tissue at the lower border of the sep- 
tum, which could not be easily penetrated. A diamond-shaped 
opening is thus established, which is sufficiently near to the floor of 
the antrum to afford ample drainage facilities, and is also easily ac- 
cessible for subsequent cleansing and medicating procedures, which 
are essentially the same as those mentioned in connection with the 
alveolar opening. The hemorrhage attending the operation is but 
trivial, and can easily be controlled. Mickulicz states that the opera- 
tion is impracticable if the entrance is very narrow, or the bones very 
hard, or when there is extreme hypertrophy of the lower turbinated 
bone. It need scarcely be stated that the operation should be done 
with the use of cocaine, which in every case, I think, would so far 
eliminate the turbinated hypertrophy, by contracting the tissues, as 
to overcome any obstacle that that condition might present. If 
the septum by its deflection hamper the manipulation, it can easily be 
removed by means of the saw. If the bone is found to be sufficiently 
hard to resist penetration by the knife, a burr or drill, or perhaps 
Curtis' trephine, can be manipulated by the dental engine or electro- 
motor. 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 261 

Mickulicz's operation does Dot open the antrum at its lowest por- 
tion, yet it is sufficient practically to afford ample drainage of the 
sinus, and I fully agree with Frankel in the view that the antrum 
should be opened in the lower meatus, in preference to any other 
locality, unless a carious molar tooth invites the alveolar opening. 
There may be conditions rendering it necessary to make the opening 
through the canine fossa, such as ankylosis of the jaw, preventing the 
removal of a tooth, in connection with insuperable objections to Mick- 
ulicz's operation. An opening in this region offers no special advan- 
tages, while the wearing of a drainage tube in this locality might 
prove a source of considerable annoyance, and, furthermore, it is 
usually a matter of some difficulty to keep the opening patulous. 
In those cases in which, as the result of the long retention of pus, the 
anterior wall of the antrum has become thin, and the pus shows a 
tendency to point upon the cheek, this disposition should be cor- 
rected as soon as possible, by an artificial opening elsewhere, since it 
is probably never wise to open the antrum through the cheek, as, in 
that case, a permanent fistulous opening is liable to form. 

Diseases of the Ethmoidal Sinuses. 

Ethmoidal disease, both from the anatomical character of the 
regions involved, and with reference to the symptoms to which it 
gives rise, differs essentially from diseased conditions found in any 
of the other accessory cavities of the nose. For whereas the maxil- 
lary, frontal, and sphenoidal sinuses present to us a single cavity 
confined by bony walls, the ethmoidal cells consist of a large quad- 
rangular mass of small cells, or trabecular, varying in size, and each 
cell more or less completely separated from its neighbor by a thin, 
bony partition. Hence while the problem which presents itself to us 
in dealing with morbid conditions in the other cavities consists 
simply in making an opening for proper drainage and irrigation, in 
dealing with diseased processes in the ethmoidal cells the radical 
arrest or cure of the disease, especially when suppuration has taken 
place, demands the opening of each of the large number of small cells 
which compose this mass. This is impossible. Hence we are com- 
pelled to resort to the breaking down of these small partitions within 
the ethmoid body, in such a way as to convert it intp one single cav- 
ity. And here, perhaps, it may be proper to say that in a diseased 
condition of any of the accessory cavities I think we will all recog- 
nize the fact that the tendency in every case of a simple inflamma- 
tory process which does not undergo resolution and which develops 
into a chronic inflammation is to result in suppurative action, and 



262 DISEASES OF THE NASAL PASSAGES. 

thus the establishment of a more or less permanent pus discharge 
through the normal opening, namely, into the nasal cavity. The 
other respect in which disease of the ethmoidal cells differs from that 
of the larger sinuses is that whereas in the latter we have simply 
a purulent discharge, in the former diseased action sets up a train 
of symptoms more or less neurotic in character, such as watery dis- 
charge from the nose; violent sneezing attacks, asthma, headache, 
neuralgias, which according to Berger and Tyrman are usually inter- 
mittent in character ; certain disturbances in the muscular control of 
the eyeball ; asthenopia ; and especially what has been called apro- 
sexia. This latter really constitutes one of the most distressing 
symptoms of the disease, and has been described to me by patients 
as a sort of blanket over their brain, which interfered with mental 
activity and the free use of their faculties. 

I regard ethmoidal disease as not only by far the most frequent 
of all diseases of the accessory cavities, but as of very much more 
frequent occurrence than we ordinarily have been taught to believe, 
as will be inferred by the statement that in the past five years ninety- 
eight such cases have come under observation in my private practice. 

In the chapter on acute rhinitis, in all of our text-books on throat 
diseases, there is described a disease characterized often by nasal 
stenosis, frontal headache, intra-orbital pressure, asthenopia, watery 
discharge, and violent sneezing, which I very frankly confess I have 
rarely seen when I was enabled to detect a rational explanation of 
the symptoms in the morbid condition of the nasal mucous mem- 
brane alone, as seen by ocular inspection. I contented myself with 
the old teaching that these symptoms were to an extent reflex in 
character. I do not hesitate to say that I believe a very large pro- 
portion of the cases of so-called acute rhinitis are really instances of 
acute ethmoiditis, and that such inflammation as may exist in the 
nasal mucous membrane is really secondary to the graver and more 
distressing conditions of the lining membrane of the ethmoidal cells. 

Among the cases which I shall briefly analyze later are a number 
of instances, both of acute ethmoiditis and suppurative disease, 
which have had their onset in unmistakable attacks of la grippe, 
which leads me to hazard the suggestion as to whether the influenzal 
type of la grippe is not really an invasion of the ethmoid cells by 
the specific bacillus which is supposed to be the exciting cause of 
that disease. 

In a paper on ethmoid disease, I have described five varieties of 
diseased conditions of these cells, which practically reduced them- 
selves to three, viz. : first, extra-cellular myxomatous degeneration ; 
second, intra-cellular myxomatous degeneration ; and third, purulent 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 2(33 

ethmoiditis ; I think that these three conditions are successive stages 
of one and the same disease. An acute inflammatory process of the 
mucous membrane lining these cells very soon either results in reso- 
lution or a chronic morbid process. Owing to the peculiar anatomi- 
cal character of this membrane, a chronic inflammation tends to 
develop a soft jelly-like thickening of the tissue, which takes on 
what we may describe as a myxomatous character. Now, this may 
persist for a somewhat prolonged period of time, giving rise to dis- 
tention of the cells, with its train of symptoms already alluded to, 
which are watery or muco-purulent discharges, violent attacks of 
sneezing, headache, intra-orbital pressure, aprosexia, etc., and, if the 
constitutional habit be neurotic, hay-fever and asthma, these symp- 
toms being simply exaggerated on the occurrence of more or less 
frequently repeated attacks of acute inflammation, to which the 
patient is liable. 

The further course of this disease I take to be, in a certain 
small percentage of cases, the crowding out from the ethmoid cells, 
through the normal opening, of this myxomatous tissue, which pre- 
sents in the nasal cavity in the form of small polypi. Not that I 
believe the large proportion of cases of nasal polypi have their origin 
in the ethmoidal cells, for Zuckerkandl has demonstrated conclusively 
that this is not the case. As the result of this inflammatory process 
within the cells, the thin walls become distended and we have a 
somewhat curious development by which the outer wall of the cells 
yields before the pressure, and we have the middle turbinated bone 
crowded outward, and gradually an extension of these cells into this 
body. And here for the first time there presents a condition by 
which we may recognize a morbid process in the ethmoid cells by 
ocular inspection through the nose ; in other words, so far as rhino- 
scopic examination goes, in the inflammatory stage of the disease 
this distention of the cells and extension into the middle turbinated 
body gives rise to a protuberance into the middle meatus, which is 
easily recognized, the middle turbinated body presenting as a 
rounded, ovoid mass, usually in contact with the septum and en- 
croaching notably upon the middle meatus of the nose. At the 
same time this curious myxomatous degeneration of the mucous 
membrane and lining cells conveys itself to the mucous membrane 
covering the outer wall, which is now the middle turbinated body in 
the nose, and lends additional aid in the recognition of the condition. 

The next stage in the development of the disease consists in sup- 
puration. The time of its development may be very early or very 
late in the history of the disease, this being governed somewhat by 
adventitious circumstances. The method of this development seems 



264 DISEASES OF THE NASAL PASSAGES. 

very clear. The inflammatory process involving the membrane 
within the cells necessarily gives rise to hypersecretion, which mate- 
rially contributes to the intracellular distention, and also results in a 
closure of the normal orifice. The consequence is the formation of 
an acute abscess, which, failing resolution, soon develops into a 
chronic abscess or chronic suppuration of the cells. We thus have 
established a chronic suppurative disease. The pus finds its exit 
through either the anterior or posterior ethmoidal cells ; and I may 
state here, from a practical point of view, that the anatomical division 
of these cells into the anterior and posterior group is of no special 
interest to us in dealing with the diseased conditions, in that I 
believe they are really converted into a single group of cells, by 
either a normal or a rapidly established abnormal opening between 
the two. The pus makes its way into the nasal chambers through 
one of the normal openings, either in front into the hiatus semi- 
lunaris, or through the posterior opening into the superior meatus. 
Thus on ocular inspection we may find the pus making its appearance 
either from beneath the middle turbinated body or from between the 
middle turbinated body and the septum above. As a rule, the pus 
from the anterior and lower opening makes its way into the lower 
meatus and is expelled through the anterior nares, while the dis- 
charge from the posterior opening makes its way into the pharynx, 
giving rise to the symptoms so often complained of, viz. : that of 
dropping in the throat, in which way the disease may be confused 
with an ordinary naso-pharyngeal catarrh; although I should say 
here that the secretion of this latter disease is usually thick and 
adherent, and is expelled by somewhat violent nasal screatus, whereas 
dropping in the throat should always suggest the great probability 
of an empyema of either the ethmoidal cells or the sphenoidal sinus. 

While the most natural exit for the pus is into the nasal cavity, 
this is by no means its invariable course, as is shown by the large 
number of cases in which the pus escapes through the os planum 
into the orbital cavity, giving rise to exophthalmos and orbital dis- 
ease. Furthermore, we occasionally meet with exophthalmos from 
distention of the cells in the cavity, without escape of pus, as is still 
further and notably illustrated by the case reported by Bull, of eth- 
moidal suppuration, in which an artificial puncture through the 
orbit was followed later by a spontaneous rupture into the nasal 
cavities, the ultimate cure resulting probably from the latter. 

As the result of the persistent suppuration, the lining membrane 
of these cells necessarily become soft and very much thinned. The 
much-discussed question of necrosis of bone never has interested me 
greatly, because I regard its importance as much overestimated. 



DISEASES OF THE ACCESSORY SINUSES OF THE XOSE. 265 

That treatment should be instituted early in the history of the 
disease and before the suppurative process has ensued need not be 
urged, in view of the very serious discomfort and even danger which 
attends the stage of empyema, and the great difficulty with which it 
is brought under control after pus formation has become chronic. 
In acute ethmoiditis the ordinary measures which our text-books 
recommend in the treatment of acute rhinitis are indicated of course, 
and need not be dwelt upon, further than to say that of all measures 
I regard the use of the douche as most potent, and advise that from 
one to two gallons of water rendered thoroughly saline be passed 
through the nasal cavities by means of the Thudicum douche, at 
least twice daily. The water should be as hot as can be borne. 
This instrument I regard as devoid of danger to the ears, provided 
that the patency of each nostril be tested before its use and that the 
stream be made to pass into the narrowest naris, thus emerging with- 
out obstruction from the most patent side. 

When the disease has reached the chronic stage without suppura- 
tion, I believe that, other measures failing, surgical interference 
should be resorted to in all cases, as we here have to deal with an 
affection which does not tend to undergo resolution, but one in which 
there is imminent danger of suppuration setting in at any time. 
The test that this chronic stage has been reached is to be found in 
the swollen and distended condition of the ethmoid cells, as shown 
by the projecting and swollen turbinated body, whether the mucous 
membrane covering it be in a state of myxomatous degeneration or 
simply turgescent. The object to be accomplished is to relieve 
intracellular pressure, and this is accomplished by uncapping, as it 
were the ethmoid cells. The steel-wire loop of the Jarvis or Bos- 
worth snare is easily slipped over the projecting turbinated body, 
and the whole mass removed, presenting usually in the form of an 
elongated ovoid shell. This also reveals to us the condition of the 
mucous membrane within the ethmoid cells, which may be either in 
a simple state of turgescence, or, as has not infrequently happened 
in my own experience, a soft, gelatinous mass of myxomatous tissue 
is found filling the cavity thus opened. If this does not drop out of 
place, it is very easily removed by the mouse-tooth forceps or the 
snare. 

After pus formation has occurred the problem before us, as before 
stated, consists in converting the large number of small cells which 
compose these bodies into a single cavity and establishing thorough 
drainage. In these cases the primary procedure is, as before, to 
uncap the cells by use of the snare, and after that I believe our best 
instrument is the dental burr. I have never been able to freely 



266 DISEASES OF THE NASAL PASSAGES. 

manipulate the curette or the sharp spoon in the ethmoidal cells or 
to break down the trabecular walls by their use. 

That this disease can be radically cured, or even modified or con- 
trolled to any great extent, by the use of disinfecting lotions, I do 
not believe. The small oval or round burr attached to the dental 
engine, or, better still, the De Vilbiss engine, in my hands has an- 
swered a better purpose than any other device. Manipulated with 
the De Yilbiss engine, it is made to enter the ethmoidal cells either 
before or after they have been uncapped, when the trabecular walls 
are easily broken down or burred away. Its motion can be instantly 
arrested at will, when it can be made to act as a probe, exploring the 
cavity for exposed bone or such parts as it is desired to remove. In 
this manner our operation becomes not only intelligent, but, I think, 
absolutely safe, a consideration which of course is to be very care- 
fully borne in mind when we remember that not only are we separated 
in our operation from the orbit of the eye by an exceedingly thin 
plate of bone, but if we progress very far we are getting in close 
proximity to the base of the brain. In many of my cases the opera- 
tions have been repeated a number of times at intervals varying from 
one week to a month, or even longer to secure thorough drainage. 
During the intervals of course the patient is directed to use disin- 
fecting lotions with as much intelligence and thoroughness as can be 
accomplished by the ordinary devices which we place in the hands of 
our patients for use. I have no special suggestion to make as to 
the character of these lotions, as thoroughness of application is of 
more value than the special character of the antiseptic used. More- 
over, it should be stated that the operation is not attended with any- 
thing like the pain that we should suppose when we consider the 
exceedingly sensitive character of the parts operated upon, provided 
that we can reach the parts in such a manner as to thoroughly satu- 
rate them with a cocaine solution. 

Of 97 cases met with in my own practice, 3 were of carcinoma and 
1 of sarcoma of the ethmoidal cells, which may be left out of con- 
sideration. As regards age, 3 occurred in the second decade of 
life, 14 in the third, 23 in the fourth, 28 in the fifth, 18 in the 
sixth, and 7 in the seventh decade. Sixty-one were males and 32 
were females. Fifteen cases were inflammatory in character without 
suppuration or polypoid degeneration. Of these, 9 were cured, 3 
were improved, and 3 disappeared. Twenty-nine cases showed 
myxomatous degeneration without suppuration. Of these 12 were 
cured, 10 improved, and 7 were seen but once or twice and their 
progress is not known. Twenty-two cases showed myxomatous degen- 
eration or fully developed polypi together with pus discharge. Of 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 2G7 

these, 9 were cured, 10 improved, and 3 disappeared. Of the 
purely suppurative cases there were 27, of which 8 were cured, 
12 improved, both as regards subjective symptoms and the amount 
of discharge, while 7 were seen but once or twice and not further 
noted. In nearly all these cases radical operative measures were 
instituted, as carrying out the suggestions already made. In many 
of them the simple irrigating measures failed to give relief, either 
to subjective or objective symptoms, and the cells were opened either 
by the saw or drill. In many cases both were used. 



Diseases of the Sphenoidal Sinuses. 

Simple catarrhal inflammation of the mucous membrane lining the 
sinuses of the sphenoid bone occurs probably not infrequently as a 
complication of an acute rhinitis, as is the case with the other acces- 
sory sinuses. This, however, is not evidenced by any very marked 
symptoms, and it may undergo resolution, with the subsidence of the 
nasal disorder. Suppurative disease in this region, however, con- 
stitutes an affection of very serious import, in that, as in the other 
sinuses, it manifests but little disposition to undergo a spontaneous 
cure, but on the contrary, gradually extends to the deep layers of the 
membrane and the periosteum, resulting in a bony necrosis. 

Etiology. — The course and development of this morbid process 
is much the same as we find it in the other accessory sinuses, 
and it probably arises primarily from obstruction of the ostium sphe- 
noidale, resulting in a retention of secretion, with consequent sup- 
purative inflammation. This obstruction may result from the en- 
croachment of hypertrophic inflammation of the mucous membrane 
lining the nasal cavities, the existence of polypi or other tumors, the 
presence of foreign bodies, or some deformity of the nasal cavity, 
which acts to occlude the normal orifice. Zuckerkandl raises the 
question whether in certain cases the necrosis may not be primary, 
and the pus discharge a resultant symptom, although favoring the 
view that in the majority of instances the necrosis is the result 
of a morbid process in the mucous membrane. Purulent accumu- 
lations in these sinuses have been observed in connection with cere- 
brospinal meningitis; and syphilis, scrofula, and facial erysipelas, 
with typhoid fever, have been given as causes of this disease. 

Pathology. — The pathological changes which take place in the 
mucous membrane of these sinuses consist essentially in a catarrhal 
inflammation, gradually extending to the deeper tissues, which here 
constitute the periosteum, as the result of which the nutrition of 



268 DISEASES OF THE NASAL PASSAGES. 

bone is so far interfered with that necrosis occurs, the simple catar- 
rhal inflammation being converted into a suppurative process, as 
the result of obstruction to the orifice and resultant accumulation of 
the secretions. Hence, we can easily see how the anatomical situa- 
tion of the orifices of the sphenoidal sinuses and the antrum favor 
the development of suppurative inflammation, being situated on the 
lateral wall of the sinus, thus differing from the ethmoidal and 
frontal sinuses, whose orifices admit of freer drainage, while Zucker- 
kandl singles out the ostium sphenoidale as being located in a manner 
particularly unfavorable to the free escape of accumulated secretions. 

Symptomatology. — More or less profuse purulent discharge from 
the nasal cavity is a prominent symptom of the disease, this pus 
being the same bright yellow healthy pus which is characteristic of 
suppurative disease of all of the accessory sinuses. The discharge 
makes its way backward, as a rule, dropping into the pharynx. Len- 
nox Browne makes the statement that " sphenoidal discharges may 
be the forerunner and possibly the excitant of obstinate post-nasal 
catarrh." This is scarcely a correct observation. Certainly the dis- 
charge excites no morbid condition in the mucous membrane over 
which it passes, and, moreover, a pus secretion does not occur in what 
is ordinarily termed a post-nasal catarrh. Deep-seated pain is 
always present, referable to the side affected, and in some cases may 
be of a most distressing character, radiating through the whole side of 
the face and involving all the branches of the trigeminus. Owing to 
the proximity of the sphenoidal sinuses to the optic foramina, ocular 
symptoms may naturally be expected, and hence impairment of 
vision or complete blindness may occur, as the result of pressure on 
the optic nerve. The notable symptoms are a pus discharge with 
pain, followed, as the disease progresses, by a somewhat sudden oc- 
currence of blindness, and in a certain proportion of cases the de- 
velopment of orbital abscess, or serous exudation into the cellular 
tissue of the orbit. 

Berger calls attention to a peculiar feature of the amaurosis oc- 
curring in connection with cases of sphenoidal disease, in that the 
peripheral field of vision is invaded before the central field is affected. 
This is explaioed by the fact, as first observed by Samelsohn, that 
the central fibres of the optic nerve are distributed to the macula 
lutea, while the peripheral fibres are distributed to the outer portion 
of the retina. 

Diagnosis.— A diagnosis of suppurative disease of one of the ac- 
cessory sinuses having been established by the existence of a dis- 
charge of bright yellow healthy pus from one of the nasal passages, 
the attention would necessarily be directed toward the sphenoidal 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 269 

sinus as the seat of the disease, by the fact of the pus pouring over 
the surface of the middle turbinated bone, and because its source can 
be traced to the superior meatus, provided the nasal passages are suffi- 
ciently patulous to admit of a thorough exploration. It should be 
stated, however, that this nice localization of a purulent discharge in 
this region is very rarely possible by an examination anteriorly, 
although it may occasionally be accomplished by posterior rhinoscopy. 
In those cases of ethmoidal disease in which the posterior group of 
cells is involved, we may also have a pus discharge into the superior 
meatus. In these cases, the recognition of the disease will neces- 
sarily be based on a consideration of concomitant symptoms, although 
it should be stated that probably, in the majority of cases in which 
the posterior group of ethmoidal cells is the seat of the disease, the 
sphenoidal sinuses are involved in the same morbid process, owing to 
their close anatomical relation and to the fact that the orifices both of 
the sphenoidal and posterior ethmoidal cells open together into the 
superior meatus, and hence the same causes which would operate to 
produce suppurative disease in one group would act equally in the 
other. The pus discharge makes its way into the pharynx, giving 
rise to symptoms of ordinary so-called naso-pharyngeal catarrh, 
although the character of the secretion differs essentially from the 
ordinary inspissated mucus which is found in the pharyngeal vault 
in that disease. Suppurative inflammation of the pharyngeal bursa, 
the so-called Tornwaldt's disease, gives rise to a pus discharge into 
the pharyngeal vault. This affection, however, I regard as an ex- 
ceedingly rare one, and, furthermore, a rhinoscopic examination 
should easily establish the source of the purulent secretion. Ziem 
has reported a rather interesting case, in which a somewhat profuse 
purulent discharge into both the pharyngeal vault and the nasal cavi- 
ties had its origin in a cyst of the pharyngeal bursa, the removal of 
which seemed for a while to arrest the disease, although subsequently 
it became necessary to open the antrum, on account of suppurative 
inflammation of that cavity. Further diagnostic signs pointing to 
sphenoidal disease consist of deep-seated pain, exophthalmos, paraly- 
sis of the optic nerve, or paresis of any of the motor nerves passing 
through the sphenoidal fissure. The deep-seated pain is character- 
istic both of sphenoidal and ethmoidal disease, and presents no points 
especially indicative of either affection. Exophthalmos is present in 
a large proportion of cases, but is probably not so constant a symp- 
tom of this affection as of ethmoidal disease. One of the earliest 
effects of distention of the sphenoidal sinus by pus would be pres- 
sure on the optic nerve, in its passage through the optic foramen; 
hence the sudden onset of amaurosis occurs in probably a large pro- 



270 DISEASES OF THE NASAL PASSAGES. 

portion of cases. An examination by the ophthalmoscope in these 
cases should reveal the characteristic swollen disc. Still further diag- 
nostic indications are furnished by the results of pressure on the 
nerves passing through the sphenoidal fissure, causing ptosis, strabis- 
mus, or immobility* of the eyeball. 

Coukse and Peognosis. — The prognosis of these cases, as a rule, 
is grave, as, owing to the depth and inaccessibility of the parts 
affected, and the difficulty of reaching them with proper remedial 
measures, suppurative inflammation sooner or later leads to a necro- 
sis of bone, which, extending slowly, invades the orbital cavity, pro- 
ducing paralysis of the optic nerve. Death may occur as the result 
of meningitis or as the result of invasion of the cavernous sinus by 
an erosion of its wall, as in a case reported by Scholz, in which the 
primary seat of the disease was in the sphenoidal cells. Cases of 
thrombosis of the circular and cavernous sinus and of the ophthalmic 
veins have occurred. A somewhat unique case is reported by Bara- 
toux, in which nature effected a cure by the spontaneous expulsion of 
the whole body of the sphenoid through the nose, the singular feature 
of the case being that during the course of the disease there were no 
symptoms of meningeal irritation nor impairment of vision. 

Treatment. — The same palliative measures are indicated here as 
noted in the directions for treatment of ethmoidal and antral disease. 
These consist in the use of cleansing and disinfecting sprays and 
washes, together with politzerization, either anteriorly or posteriorly 
according to Ziem's method. These should be used frequently and 
with all thoroughness, in order to secure as efficient drainage of 
the diseased cavity as is possible in this manner. The indications 
for the radical treatment of the disease consist simply in opening the 
cavity for the discharge of pus in its early stages, and the removal of 
necrosed bone, when feasible, in its later development. Zuckerkandl 
advises the opening of the sphenoidal sinus through the nasal cavity, 
at its anterior and dependent portion, whereby the most efficient drain- 
age may be secured. He directs that a trocar shall be introduced 
along the septum, passing upward and backward, across the middle 
turbinated bone, about at the junction of its posterior and middle 
third, until it reaches the anterior wall of the sphenoid cells, when it 
is pushed directly into the cavity. Zuckerkandl 's advice is based 
entirely on anatomical study of the cadaver. This operation demands 
great manipulative dexterity and great care, as there is some risk of 
entering the cranial cavity. After an opening has been established, 
the further treatment of the disease consists in daily washing out the 
cavity, by means of cleansing and disinfecting lotions, while at the 
same time the patency of the orifice is maintained by proper means. 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 271 

If bony necrosis is found to exist, it should be removed so far as pos- 
sible, under the general rules of ordinary surgical procedure. If this 
is limited in extent, a small curette through the artificial opening 
would probably accomplish all that is required. If, however, the 
necrosis has extended to the body and wing of the sphenoid, its re- 
moval can be accomplished only by access through the orbit. 

Disease of the Frontal Sinuses. 

While simple catarrhal inflammation of the mucous membrane of 
the frontal sinuses occurs in connection with a cold in the head more 
frequently than that of any of the other accessory cavities, suppu- 
rative inflammation, on the other hand, is one of the rarest occur- 
rences. This is probably due to the fact that the infundibulum 
opens from the most dependent portion of the cavity, thus affording 
free drainage, while, at the same time, it is probably less liable to 
become firmly occluded. We find, then, here an accessory sinus, in 
which the anatomical conditions favoring the development of suppu- 
rative disease are absent. Thus, Zuckerkandl states that he has never 
met with a single instance of uncomplicated disease of this sinus. 

Etiology. — The disease may arise as the result of any condition 
causing occlusion of the orifice of the sinus, such as hypertrophic 
rhinitis, deflection of the septum, the presence of tumors in the nasal 
cavity, or any other obstructive lesion in the nasal passages. This, 
however, is an exceedingly rare event. Far more active agents in 
the production of the disease are traumatism, maggots in the nose, 
gonorrhoea, syphilis, scrofula, disease of the ethmoidal sinus, or the 
development of tumors within the sinus itself. 

Pathology. — The changes which take place in the membrane con- 
sist briefly in hyperemia, with hypersecretion, which, as the result 
of retention, gradually changes into a suppurative process, and in 
connection with this the morbid process gradually invades the whole 
thickness of the mucous membrane, causing marked tumefaction with 
resultant periostitis and the development of exostoses or bony plates. 
In fact, the pathology of disease of the frontal sinus differs in no re- 
spect from that of disease of the antrum already described. 

Symptomatology. — The earliest symptom, which should direct at- 
tention to a diseased condition of these sinuses, is frontal headache, 
which may develop into pain of an exceedingly distressing character, 
increasing as the accumulated secretions gather and distend the sinus. 
A certain amount of relief is gained with the escape of pus, which, 
flowing into the nasal cavity, is discharged through the nose. It is 
bright yellow, and at first is exceedingly offensive in character. As 



272 DISEASES OF THE NASAL PASSAGES. 

the flow becomes established, however, the fetor in a measure disap- 
pears. The headache is usually persistent, although occasionally it 
may assume an intermittent type. It is increased by mental effort, or 
by the use of alcohol, and at times assumes the character of sick head- 
ache, being attended with nausea and vomiting. If the pus accumula- 
tion in the sinus is large and its exit obstructed, the roof of the orbit 
may be so far crowded downward as to produce displacement of the 
eyeball with diplopia or amaurosis. At the same time, the anterior 
wall of the cavity may be so far displaced as to produce notable facial 
deformity. If the posterior wall of the sinus is displaced, it will be 
indicated by symptoms referable to the brain, such as dulness or 
apathy, with increased headache, or sleepiness. The brain symp- 
toms, however, are very apt to be obscure, as is usually the case when 
pressure occurs on the anterior lobes, although Otto, as quoted by 
Schech, cites a case in which displacement of the posterior wall of the 
sinus gave rise to unilateral paralysis. If the disease goes on so far 
as to produce erosion of the posterior wall, with the escape of pus into 
the brain cavity, the ordinary symptoms of meningitis supervene; on 
the other hand, a cerebral abscess may develop without perforation of 
the bony wall of the sinus. In the same way, erosion of the roof of 
the orbit may occur, resulting in the escape of pus and the develop- 
ment of an abscess in this cavity. In this connection it should be 
borne in mind that a congenital defect occasionally occurs in the de- 
velopment of the bones of the orbit, by which a permanent opening 
exists in this plate, through which pus from the frontal sinus may 
make its way into the orbital cavity, without erosion or necrosis. 

Diagnosis. — The history of the case will often afford diagnostic 
points, leading to the suspicion of the existence of frontal disease, as 
gonorrhoea, maggots, syphilis, etc. The pus discharge presents the 
ordinary characteristics of disease of the accessory sinuses, and makes 
its appearance in the nasal cavity as a bright yellow healthy pus 
flowing over the middle turbinated bone, rather nearer the anterior 
extremity ; it is discharged usually through the nostril. In connec- 
tion with this the diagnosis usually should be fairly well established, 
by the existence of frontal pain, tenderness upon pressure, possible 
dulness on percussion, as compared with the opposite side, and, if 
distention occurs, the gross evidences of the disease as shown by ex- 
ternal deformity or displacement of the orbital plate. 

Pkognosis. — Simple catarrhal inflammation of the frontal sinus 
usually undergoes resolution spontaneously. In suppurative disease 
this tendency is not remarkable, and, although the prognosis is rarely 
grave when the disease is uncomplicated, its course is somewhat 
lengthened and tedious unless arrested by proper remedial measures. 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 273 

Its tendency is not toward the development of necrosis, but to the 
accumulation of pus in the sinus, with distention and encroachment 
upon neighboring cavities. 

In two cases reported by Pettesohn, nasal discharge had been a 
symptom for some time. There was a tumor at the supranasal angle 
of the orbit and oedema of the upper lid. Both patients were cured by 
incision. 

Treatment. — The primary treatment of the affection consists in 
the use of cleansing disinfectant lotions in the nasal cavity by means 
of the syringe or atomizer, in order to remove such secretions as may 
lodge in this region, and at the same time establish, so far as pos- 
sible, free drainage through the normal opening. This, however, in 
many cases fails to accomplish all that is desired, and hence it be- 
comes necessary to make an artificial opening into the sinus through 
the bony walls, of sufficient size and accessibility to admit of their 
thorough cleansing, and at the same time secure free drainage. 
The point usually selected for this operation is immediately below the 
eyebrow and near the bridge of the nose ; an incision having been 
made through the integument, the periosteum is elevated, and sub- 
sequently the perforation made into the frontal sinus by means of a 
drill, trocar, or trephine. In this manner the opening is made as 
nearly as possible in the dependent portion of the cavity. When an 
orbital abscess exists, of course the first indication is to open this by 
free incision, after which an exploration with a probe could reveal, in 
most cases, an already existing perforation of the orbital plate, and in 
those rare instances in which no opening exists here the bone will 
be found to be in a condition which will easily permit of perforation. 
The opening must be made sufficiently large to give free access 
to the sinus. It would seem that, even when no orbital abscess ex- 
ists, we have at the upper and inner angle of the orbit, just within the 
supra-orbital ridge, a site which might well be chosen for an artificial 
opening, in that the bony plate is quite thin, and while the cavity 
could be surely and thoroughly opened, the resulting cicatrix would 
be less noticeable. When the infundibulum is obstructed, it is a 
matter of considerable importance, even after the artificial opening 
irt:> the frontal sinus has been established, to reopen also the normal 
orifice, in order that proper through-and-through drainage may be 
secured. Schech advises the dilatation of the normal orifice by means 
of a probe passed through the artificial passage resulting from open- 
ing the frontal sinus, and if necessary the forcible passage of a trocar 
through into the nasal cavity and the insertion of a drainage tube into 
the opening thus made. Such a procedure, however, would rarely be 
necessary. After access has been gained to the sinus, thorough ex- 
18 



274 DISEASES OF THE NASAL PASSAGES. 

ploration should be made with a probe, which should reveal the pres- 
ence of necrosis or tumors, and, furthermore, would make known the 
involvement of the neighboring sinuses if such exist. 

In some cases it would seem that the disease may be cured by the 
removal of such obstructing lesion as may be found in the nasal 
cavity ; thus Schmiegelow has reported a case of suppurative disease 
of the frontal sinuses cured by the removal of nasal polypi. Seiss 
goes so far as to state that in the majority of cases the disease can be 
controlled by " pinning down" the swollen tissues in the nasal cavity 
which occlude the normal orifice, using applications of chromic acid, 
after the manner described in Chapter IX. While not indorsing so 
broad a statement, I am disposed to think that much can be ac- 
complished by measures of this character ; as stated in discussing the 
subject of disease of the antrum, I believe that suppurative disease is 
set up in this cavity as the result of a morbid process in the nasal 
cavity far more frequently than in any of the other accessory sinuses. 



Differential Diagnosis between Disease of the Accessory 

CAVnTES. 

While the recognition of suppurative disease of one of the acces- 
sory sinuses of the nose is comparatively an easy matter, the deter- 
mination of which cavity is affected is often involved in considerable 
obscurity, and hence it would seem not out of place to group to- 
gether here the different symptoms, with their special diagnostic 
significance. 

A pus discharge from the nose is characteristic of diseases of all 
the sinuses, excluding those exceptional cases in which the normal 
orifice is completely occluded, in which event the abscess is forced, as 
it were, into neighboring regions, such as the orbital or cranial cavity. 
In antral and frontal disease, and in disease of the anterior ethmoidal 
cells, the pus makes its way anteriorly and is discharged from the 
nostril, while in disease of the posterior ethmoidal and the sphenoidal 
sinuses, it makes its way into the pharnyx. In antral disease, the 
discharge is intermittent, and shows a certain degree of periodicity. 
In disease of the other cavities it is usually continuous. Inclining the 
head well forward, or lying on the unaffected side, favors a discharge 
from the antrum, while the upright position favors a discharge from 
the other sinuses. 

Unilateral pain is present in all the affections. In antral diseases, 
this is most marked in the region of the cheekbone and teeth. In 
frontal disease, it becomes a frontal headache, while in the ethmoidal 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE. 275 

and sphenoidal affections it is more deep-seated, and locates itself at 
the roof of the orbit. 

Exophthalmos is the rule in ethmoidal disease, but is also met 
with somewhat frequently in connection with disease of the sphenoidal 
sinuses. It is exceedingly rare in connection with disease of the 
antrum, and occurs only when the abscess ruptures into the orbit. 
In frontal disease bulging of the orbital plates is not a rare event, 
but in this case the eye is apt to be crowded downward and outward, 
so that the eyeball is not protruded to the same extent as is liable to 
occur iD ethmoidal disease. Diplopia, when present, is the result of 
displacement of the eyeball, and therefore constitutes a diagnostic sign 
of no additional value. 

Sudden blindness is due to pressure on the optic nerve as it passes 
through the optic f oramefi, and is, therefore, met with only as a symp- 
tom in connection with sphenoidal disease; although, as Ziem has 
shown, the field of vision may be narrowed in disease of the antrum. 

Ptosis is the result of pressure on the third nerve as it passes 
through the sphenoidal fissure. This also, therefore, would point to 
involvement of the sphenoidal labyrinth. 

Strabismus would be occasioned by a certain differentiation of the 
pressure on the nerves passing through the sphenoidal fissure, and 
would also indicate the existence of sphenoidal disease. 

Facial neuralgia may occur in connection with disease of any of 
the sinuses, although it is most constantly met with in disease of 
the antrum, less frequently in connection with sphenoidal disease, 
and with the greatest rarity in connection with ethmoidal and frontal 
disease. 

Fetor is present in a very mild degree in disease of all the sinuses, 
and may possess a certain amount of intermittency as suggested by 
Luc, thus pointing more directly to disease of the antrum, in that the 
fetor probably attends the escape of pus after a temporary retention. 

The frequency with which the different sinuses are affected by 
suppurative disease affords a certain amount of aid in diagnosis. 
Antral disease is by far the most frequently met with, while in the 
order stated the disease is less frequent in the ethmoid and sphenoid 
sinuses, while suppurative disease of the frontal sinus is the rarest of 
all. 



SECTION II. 

DISEASES OF THE NASOPHARYNX, 



DISEASES OF THE NASOPHARYNX. 



CHAPTER XXXIX. 

THE ANATOMY AND PHYSIOLOGY OF THE NASO- 

PHAKYNX. 

In our consideration of the subject I prefer the use of the term 
naso-pharynx as clearly defining that space which lies behind the 
posterior nares and the oral cavity, and which has been described. 

Anatomy of the Naso-Phaeynx. 

This cavity consists of a quadrilateral space, lying behind the 
posterior nares, and bounded as follows : Its roof is formed by the 
basilar process of the occipital bone, together with a small part of 
the posterior portion of the body of the sphenoid, while it terminates 
below in an imaginary plane opposite the border of the palate. The 
posterior wall is formed by the spinal column, the prominence of the 
arch of the atlas being often recognized at about the point where the 
vertex of the palatal arch in contraction impinges upon the pharyngeal 
wall. From this upward, the wall curves forward. The anterior 
boundary is formed by the two oval openings of the posterior nares, 
together with the posterior border of the vomer or septum, which 
presents a somewhat sharp edge below at its articulation with the 
hard palate, but expands somewhat above, to articulate with the ros- 
trum of the sphenoid. Each lateral wall is marked by the opening of 
the pharyngeal orifice of the Eustachian tube, which presents as a 
somewhat elongated or ovoid funnel-shaped orifice. The opening of 
the tube is partially surrounded by a well-defined cartilaginous ridge, 
which is mainly formed by a projection of the cartilage which enters 
into the formation of the tube proper. This eminence is very well 
marked posteriorly and above, while anteriorly it is less prominent, 
and immediately below the orifice it is absent. As the mucous mem- 



280 DISEASES OF THE NASOPHARYNX. 

brane is reflected over this cartilaginous ridge or cushion of the 
Eustachian orifice, as it is usually termed, it is thrown into a fold, as 
it passes from the lower termination of the posterior section of the 
ridge to the pharynx below, forming what has been designated by 
Luschka as the plica salpingo-pharyngea, while by its reflection from 
the anterior portion of the ridge a less prominent fold is formed, 
which extends from the anterior border of the tube to the soft palate. 
This is called by Luschka the plica salpingo-palatina. Immediately 
behind the Eustachian orifice, and lying between the cartilaginous 
cushion and the posterior wall of the pharynx, is noticed an elongated 
depression, the fossa of Rosenmuller. This fossa varies somewhat in 
shape and depth in different subjects, although it is usually elongated, 
and much broader above than below, and is mainly of interest in that 
in introducing a Eustachian catheter, its point is usually first engaged 
in this depression. While at rest the Eustachian orifice is closed, 
and is opened only as the result of muscular contraction in the various 
functional movements of the fauces. 

The muscle which acts most prominently as a dilator of the tube 
is the tensor palati muscle, or, as it is generally named by otologists, 
the spheno-salpingo-staphylinus, or the dilator tuhse. It arises from 
the base of the internal pterygoid plate of the sphenoid bone and the 
scaphoid fossa, and from the cartilaginous portion of the Eustachian 
tube throughout its whole length. It then passes downward, forward, 
and inward, and winds around the hamular process of the sphenoid, 
and is inserted into the soft palate. It enlarges the calibre of the tube 
by drawing its anterior cartilaginous margin downward and forward. 

The levator palati, whose action is less marked than the action of 
the former in opening the Eustachian tube, and yet undoubtedly 
possesses a certain function in this direction, is a long, rounded, 
muscle, arising from the petrous portion of the temporal bone, and 
from the cartilaginous portion of the tube, from which, passing down- 
ward and inward, it spreads out into a broad tendon, and is inserted 
with its fellow into the median line of the soft palate, the fibres 
blending with the mucous membrane of this structure. By its con- 
traction it lifts, as it were, the lower edge of the collapsed tube into 
such a position that its lateral walls separate, and the lumen becomes 
patulous. 

The palato-pharyngeus, which arises from the soft palate, the 
posterior portion of the hard palate, and from the cartilaginous por- 
tion of the Eustachian tube, passes downward to the thyroid cartilage, 
some of the fibres blending with the corresponding muscle of the op- 
posite side. Its action is to fix the cartilaginous portion of the tube 
to which it is attached, and thus aid the action of the levator palati. 



ANATOMY AND PHYSIOLOGY OF THE NASO- PHARYNX. 281 

The orifice of the Eustachian tube is usually described as opening 
into the anterior and lower portion of the lateral wall of the naso- 
pharynx, opposite the posterior termination of the lower turbinated 
bone, from which it is distant about three-eighths of an inch, while 
its average distance from the nostril is from two and three-quarter 
inches to three and one-fifth inches. Kostonecki, however, has shown 
that there are very great variations in the locality of this orifice, as re- 
gards its vertical position, in that in many cases it is found much 
higher in the lateral wall of the pharynx than in others. This fact, 
however, is constantly brought to the notice of otologists in passing 
the Eustachian catheter, for in many cases the tip must be carried 
well upward, in order to engage in the tubal orifice. 

The cavity of the upper pharynx differs greatly in different indi- 
viduals, without reference to their physical development. Luschka's 
measurements, however, are as follows: its vertical and anteropos- 
terior measurements are about the same, viz., three-quarters of an 
inch, while its width is about one and three-eighth inches. 

The fibrous basement structure of the naso-pharynx consists of a 
thick aponeurosis, which has its attachment to the basilar process of 
the occipital bone and the petrous portion of the temporal. Beneath 
this tissue are found certain muscular structures involved in the 
movements and support of the head. Its internal surface is lined 
with mucous membrane, which differs in no essential features 
from the mucous membrane of the respiratory tract. It is richly en- 
dowed with mucous glands, of both the tubular and racemose varieties, 
while its epithelial surface is covered with columnar ciliated epithe- 
lium. 

The feature, however, which gives the pharyngeal vault an especial 
interest, and also endows it with certain important functions, is the 
crowding together of a large number of glands into a distinct mass, 
in the upper and central portion of the cavity, constituting what is 
known as the pharyngeal tonsil, or the third tonsil, and sometimes 
called Luschka's tonsil. According to Luschka, there is always pres- 
ent in this region, although in varying degrees of development, a soft 
mass of tissue, of about one-quarter of an inch in thickness, spread 
over the roof and posterior wall of the naso-pharynx, covering the whole 
extent of the basilar process of the occipital bone. It extends the 
whole width of the pharynx, to the fossae of Eosenmuller, and even 
encroaches upon the cartilaginous eminences surrounding the Eustach- 
ian tube. The gross appearance of this mass of glands varies some- 
what, presenting occasionally a soft cushion-like outline covered 
with small rounded elevations, while in others it is traversed by fis- 
sures in various directions. The most constant appearance, how- 



282 



DISEASES OF THE NASO-PHARYNX. 




ever, and that seen in the largest majority of cases, is that in which 
the mass is traversed longitudinally by a series of fissures or indenta- 
tions, of perhaps a quarter of an inch in depth, with a slight dispo- 
sition to branch, as it were, giving rise 
to a sort of crow's foot appearance on 
the surface. (See Figs. 50, 51.) At 
the lower portion of the pharyngeal 
tonsil, in the median line, Luschka 
describes an opening, about the size 
of the head of a pin, sometimes larger, 
sometimes smaller. This opening 
leads into a small 
sac, about three- 
quarters of an inch 
long and a quarter 
of an inch wide, to 
which Luschka 
gave the name 
bursa pharyngea. 
Ganghof ner and 
Schwabach deny 
its existence as a 
distinct anatomi- 
cal structure, tak- 
ing the ground 
that this bursa, so-called, is really the recessus 
pharyngeus medius, or simply the median fissure 
of a normal pharnygeal tonsil, or possibly an hyper- 
trophied one, which, undergoing the changes in- 
cident upon maturity, has by a process of unfold- 
ing, as it were, or shrinking up upon the median 
line, resulted in an adhesion of the superficial 
layers of the adenoid tissue over the median fis- 
sure, in such a way as to form this bursa-like cavity. 
This region derives its arterial supply from the 
ascending pharyngeal branch of the external car- 
otid, and the ascending palatine branch of the fa- 
cial, together with the palatine and the spheno- 
palatine branches of the internal maxillary. The 
veins open into the internal jugular. The nerve 
supply is derived mainly from the second division of the fifth pair, 
together with branches from the glosso-pharyngeal and vagus. 



Fig. 50.— The Glandular Structures at the 
Vault of the Pharynx. (Luschka.) 1,1, 
Pterygoid processes ; 2, vomer ; 3, pos- 
terior portion of the vault of the nasal 
fossae ; 4, 4, Eustachian tubes ; 5, orifice 
of the bursa pharyngeal 6, 6, Rosen mul- 
ler's f ossee ; 7, median folds formed by the 
glandular tissues. 




Fig. 51.— Gla ndular 
Structures of the Pha- 
ryngeal Vault, seen in 
Antero-posterior Sec- 
tion. 



ANATOMY AND PHYSIOLOGY OF THE NASO-PHARYNX. 283 



Physiology of the Naso-Pharynx. 

While the naso-pharynx is situated apparently in the continuity of 
the respiratory tract, and furthermore its mucous membrane shows 
the anatomical characteristics of the mucous membrane lining the 
respiratory tract, namely, in the fact that it is covered with columnar 
ciliated epithelium, yet I am disposed to think that the function of 
the naso-pharynx has mainly to do with the food tract. The lower 
pharynx is very sparsely endowed with glandular structures. It is 
lined by a hard, dense membrane, fitted eminently to permit without 
injury the passage of harsh and oftentimes irritating particles of 
food, but it is endowed with a very scanty secreting apparatus. The 
glands necessary to furnish this region with a proper lubricant, were 
they embedded in the tissue of the lower pharynx, would be exceed- 
ingly liable to injury, from the constant irritation of food in the act 
of deglutition. Hence, we find them removed to the well-protected 
recess found between the two pillars of the fauces, where they form 
the faucial tonsils, and to the still better protected recess, the vault 
of the pharynx. In these three regions we find masses of glands, 
which pour out large quantities of mucus, whose sole and only func- 
tion is to thoroughly lubricate the bolus of food and facilitate its 
passage down into the oesophagus. 

The normal secretion from the pharyngeal tonsil consists of an 
absolutely clear, transparent, somewhat viscous mucus, of the appear- 
ance and consistency of the white of an egg. The pharyngeal vault 
being, adventitiously as it were, a part of the air tract, it is of course 
endowed with certain anatomical features characteristic of the air 
passages. 

The function of this region as a resonant chamber for the voice, 
and in connection with the auditory apparatus, will more properly 
be discussed in other chapters. 



CHAPTER XL. 

ACUTE NASO-PHABYNGITIS. 

The disease consists essentially in an acute inflammation of the 
mucous membrane lining the vault of the pharynx. 

Etiology. — Exposure to cold we regard as the prominent exciting 
cause of all acute inflammatory processes involving the mucous mem- 
brane of the upper air passages. Aside from this, I know of no cause 
for the disease. 

It is met with much more frequently in adult life than in youth. 
An ordinary cold, as we call it, in very young children occurs usually 
in connection with adenoid disease of the pharyngeal vault, or with 
the purulent rhinitis of childhood. This tendency disappears at 
puberty or perhaps before, after which an exposure results more com- 
monly in an ordinary acute rhinitis, or a typical cold in the head. 

As a secondary result of the morbid process in the nasal passages, 
the naso-pharynx becomes involved. In other words, chronic inflam- 
matory processes tend to pass downward in the air passages, carry- 
ing with them the tendency to recurrent attacks of acute inflamma- 
tion. Aside from these considerations, the predisposing causes of 
the disease will be more particularly discussed in the consideration 
of the general subject of naso-pharyngeal catarrh, in another chapter. 

Symptomatology. — The attack comes on somewhat suddenly, as 
the result of exposure, and usually is marked by notable constitu- 
tional disturbance, a flushed skin, headache, loss of appetite, etc. 
The thermometer may indicate a temperature not over perhaps 100° 
to 101° F., and yet there is frequently a malaise and feeling of ill- 
ness and prostration, which compels a patient to confine himself to 
his room or bed. 

One of the earlier sensations is a feeling of burning or dryness, 
referable to the back of the throat ; this is due to the abnormal dry- 
ness of the membrane, which, as we know, characterizes the first 
stage of all acute inflammatory processes in the upper air passages. 
This stage will often last two, three, or even four days. In connec- 
tion with this, as indicating a close connection between the naso- 
pharynx and the digestive apparatus, there is liable to be a torpid 



ACUTE NASO PHARYNGITIS. 285 

condition of the bowels, or even obstinate constipation, with complete 
anorexia and a tendency to nausea. 

The second stage of the attack is characterized by a more or less 
profuse muco-purulent discharge. This secretion consists of a some- 
what thick, grayish, opaque mucus, which is voided in considerable 
quantities. The setting in of the secretion seems, to an extent, to 
aggravate the gastric disturbance, especially giving rise to a tendency 
to nausea or vomiting, the appetite being, at the same time, consider- 
ably impaired. 

The third and last stage of the disease consists of a gradual let- 
ting up of the subjective symptoms and a diminution of the discharge. 
The voice is affected very early in the attack, and in a somewhat 
peculiar manner, which is almost characteristic of this form of cold, 
in that it has a curious, hoarse, metallic ring to it, which weakens the 
tone, although it is never entirely lost. Pain is always a prominent 
feature of this form of cold during all stages of the attack. This is 
usually referable to the roof of the mouth, or upper portion of the 
throat, from which point it seems to radiate toward the angles of the 
jaw, and may even extend up to one or both angles of the face, giving 
rise to a facial neuralgia. Certainly it occurs frequently in women of 
a nervous and perhaps hysterical temperament. Pain in the back of 
the neck is also prominent in these cases, which consists of a stiff- 
ness or soreness in the large muscles, rather than in a neuralgic pain. 
Cough is rarely met with, although a more or less disagreeable sense 
of itching or scratching about the fauces is liable to be a prominent 
source of complaint. Furthermore, the disease does not show any 
marked tendency to extend down into the trachea and bronchial tubes, 
although it almost invariably involves the lower pharynx. When we 
consider that the mucous membrane of the upper and lower pharynx 
is involved in the acute inflammation, we can easily understand how 
symptoms referable to the ear should, in most cases, be a prominent 
characteristic. In the first, or dry stage, we find frequently that 
the Eustachian tubes are closed, as evidenced by the fact that the 
patient hears his own voice with a distinctness which may be almost 
a source of distress. This symptom, however, of autophonia usually 
disappears with the setting in of the secretion. 

Diagnosis.— The diagnosis offers no difficulty. We should, how- 
ever, be careful to look for any follicular inflammation. This, of 
course, should be determined by the fact that in the exudative form of 
the disease there is a lack of the mucous secretion, while at the same 
time the characteristic white spots, marking the existence of a crou- 
pous exudation in the crypts of the follicles, are absent. Of course, 
this last point is only fully determined after a thorough cleansing 



286 DISEASES OF THE NASOPHARYNX. 

of the pharyngeal vault by means of a spray through the nose, or by 
a post-nasal syringe. Moreover, the latter disease, it should be borne 
in mind, is accompanied, especially in its earliest stages, by a temper- 
ature of from 101° to 103°, while in the catarrhal form of inflam- 
mation, the temperature rarely exceeds 100° F. 

Prognosis. — These attacks involve no special danger to life, 
although they run a somewhat prolonged course, during which time 
the patient suffers from the exceeding discomfort. The disease, 
however, shows no marked tendency to extend to the passages 
below and generally terminates in complete resolution, or, if the 
patient has previously suffered from naso-pharyngeal catarrh, it 
simply leaves behind a somewhat aggravated form of the chronic dis- 
ease. Mackenzie who alludes very casually to this affection, and 
Sajous, who devotes a chapter to its consideration, seem to sug- 
gest that the acute form of the disease may degenerate into the 
chronic. It might be stated, in this connection, that the above 
writers, so far as I know, are the only ones who refer to this form of 
a cold. 

Treatment. — At the onset of the attack, the effort should be made 
to break up the cold, in much the same way as we try to abort an 
attack of acute rhinitis. For this purpose we may give ten grains 
of quinine ; at the same time diaphoresis should be produced. 

We should bear in mind the intimate relation between the pharyn- 
geal structures and the digestive apparatus. A full dose of calomel 
or blue mass should be given with the quinine at bedtime, to be fol- 
lowed in the morning (and each morning during the existence of the 
cold) by a glass of Kissingen, Geyser, or Congress water. If head- 
ache is a prominent symptom, perhaps we have no better remedy 
than antipyrin in doses of ten grains, to be repeated every hour, 
until relief is obtained. Pain is always a prominent symptom, and 
for its relief some preparation of aconite should be given, and of 
these none is so prompt in its action as the alkaloid aconitia, admin- 
istered in the form of the tablet triturates or in granules (Duquesnel's 
preparation) in doses of ^ of a grain every hour, in the case of a 
male, and every two hours, in that of a female, until the pain is re- 
lieved, or the constitutional effect of the drug is manifested, as shown 
by numbness and tingling about the fauces or lips, vertigo, or faint- 
ness. In administering this remedy considerable care must be exer- 
cised, and when it is impossible to see a patient soon I have usually 
directed the drug in the above doses, to be taken every hour for three 
hours during the early morning, the same process being repeated 
in the early afternoon, and again in the evening if necessary. 

The best local application in this disease is a strong solution of 



ACUTE NASOPHARYNGITIS. 287 

cocaine, ior depleting the blood-vessels, after which, an application 
of chromic acid should be made after the manner already described for 
the treatment of hypertrophic rhinitis. This application will not 
only exercise a beneficial effect on the inflammatory process in the 
naso-pharynx, during the first stage, but will also serve to modify the 
nasal hyperemia which complicates the attack. As soon as the stage 
of secretion sets in, applications to the primary seat of the attack in 
the pharyngeal vault are always grateful and afford a certain amount 
of relief. For this purpose, the ordinary nasal douche, with water 
as hot as can be borne (which is made saline by the addition of com- 
mon salt), is of no little value, or the post-nasal pipe in connection 
with the nasal douche is, perhaps, still better. This may be repeated 
as often as three or four times a day. Snuffs and powders are of but 
little service in this form of disease, and may even be a source of 
annoyance. 



CHAPTER XLI. 

NASO-PHAEYNGEAL CATAEKH. 

This is a term used to designate a disease characterized by an ex- 
cessive secretion of mucus or muco-pus from the glandular structures 
of the vault of the pharyynx, and which, passing down behind the 
palate, diffuses itself over the lower pharynx, where it gives rise to 
more or less irritation, and excites a constant hawking and expecto- 
ration in connection with an annoying nasal screatus. Many and vari- 
ous have been the opinions advanced as to the causation and locality 
of this affection; the position which from the evidence we are com- 
pelled to take upon the matter is that naso-pharyngeal catarrh is un- 
doubtedly, in many cases, due to a diseased condition of the so- 
called bursa pharyngea (as Tornwaldt claimed), but it seems to me 
entirely too narrow a view of the case to say that all cases of naso- 
pharyngeal catarrh are dependent on the existence of a bursal cavity. 
Wherever we have muciparous glands gathered together in large 
masses, we have an anatomical condition which predisposes the part 
to a chronic inflammatory disease, in which the prominent lesion con- 
sists in cell desquamation, in connection with an apparent increased 
mucous secretion, and I think we are bound to accept the view that 
we may also have the same morbid condition existing in the glandular 
structures of the pharyngeal vault. A chronic inflammatory process 
involving these glands, and attended with a moderate amount of dif- 
fuse hyperplasia, may result, then, in a muco-purulent discharge 
from the broad, evenly distributed cushion of glandular structure 
spread over the pharyngeal vault, or the hyperplasia may take such a 
form as to give rise to the bursa-like cavity of Luschka or Tornwaldt. 
The formation of the bursa is a somewhat adventitious incident 
of the morbid changes which take place in the tissue, thus adding an 
entirely new condition, which serves to prolong, and possibly aggra- 
vate, the catarrhal affection. 

Etiology. — Inflammatory changes in the mucous membrane of 
young people show a marked tendency to invade the lymphatic 
structures, while in adults it is the connective-tissue structures which 
are more especially involved. Following this rule, I think we must 



NASO-PHARYNGEAL CATARRH. 289 

look for the primary source of naso-pharyngeal disease to the earlier 
period of life. An inflammatory process in children, involving the 
pharyngeal vault, gives rise to a hypertrophy of the pharyngeal 
tonsil, or so-called adenoid disease. Hence, it is altogether possible 
that, in many cases, an enlarged pharyngeal tonsil in childhood 
leads to the development, in adult life, of one of the forms of naso- 
pharyngeal catarrh heretofore described. In these cases we un- 
doubtedly find an active exciting cause in some one of the exanthems, 
especially scarlet fever or measles. After its onset, I think the dis- 
ease should be regarded in all cases as a purely local condition and 
not dependent on any general dyscrasia, although Beverley Robinson 
lays special emphasis on the fact that the disease is due not alone to 
a catarrhal diathesis but it may be and frequently is attached to the 
"gouty, hepatic, syphilitic, scrofulous, and tuberculous diatheses, 
and a malarial influence may likewise be evident, " while Moure also 
gives the first place to the strumous diathesis as the cause of the dis- 
ease. Lennox Browne, on the other hand, while making the state- 
ment in his first edition that patients suffering from naso-pharyngeal 
catarrh are generally scrofulous, seems to have abandoned this view 
entirely in his second edition. 

As regards taking cold, I am disposed to think that in most in- 
stances the chronic inflammatory process exists first, and that this 
renders the patient susceptible to atmospheric changes, and that re- 
peated colds become a symptom of the chronic inflammation rather 
than that chronic inflammation results from the repeated colds. 

The use of tobacco is supposed by some to be a cause of pharyn- 
geal catarrh. This is not based, I think, on careful clinical observa- 
tion. The effect of tobacco smoke is to aggravate temporarily, and 
perhaps permanently, an existing catarrhal lesion, while its caus- 
ative influence in the primary production of the inflammatory process 
in the naso-pharynx is very limited. 

The use of alcohol, on the other hand, is undoubtedly a prolific 
source of naso-phaiwngeal catarrh. 

By far the most frequent and most potent of all causes w T hich lead 
to the development of a naso-pharyngeal catarrh is a diseased con- 
dition of the mucous membrane lining the nasal passages proper. In 
the chapter on the physiology of the nose, the intricate and exceed- 
ingly important respiratory function of the turbinated bodies was dis- 
cussed at considerable length, and an important feature of that dis- 
cussion consisted in the assertion that the integrity of the mucous 
membrane of the whole upper air tract was directly dependent upon 
a healthy condition of the respiratory function of the nasal mucous 
membrane. If, then, we have a chronic inflammation, with hyper- 
it/ 



290 DISEASES OF THE NASO- PHARYNX. 

trophy of the nasal membrane, interfering with the normal nasal re- 
spiration, and hampering the normal process of serous exosmosis, the 
very first portion of the respiratory tract beyond the nasal cavities 
would necessarily be immediately subjected to the deleterious influ- 
ence of this impaired function. And this, I think, is shown by clini- 
cal observation, in that, as a direct result of hypertrophic rhinitis, 
we have the normal function of the pharyngeal tonsil notably inter- 
fered with, and, furthermore, its glandular structures subjected to the 
constant irritation arising thereby. As the result of this the normal 
secretion of mucus is interfered with, cell desquamation stimulated, 
and the normal mucus, which, as we have shown, is clear, white and 
easily fluid, becomes changed into a thick inspissated mucus, largely 
surcharged with unripe epithelial cells, and, in fact, becomes trans- 
formed into a muco-purulent discharge, which, adhering to and clinging 
upon its surface, hangs down between the palate and pharyngeal wall in 
thick masses of stringy mucus, which are expelled with great difficulty. 

Pathology. — The essential pathological lesion which constitutes a 
naso-pharyngeal catarrh, whether it is due to a diffuse hyperplasia 
and cell desquamation involving the whole of the pharyngeal tonsil, 
or whether it may be due to the adventitious formation of Tornwaldt's 
bursa, has been the subject of much discussion. The amount of 
secretion in Tornwaldt's disease is, as a rule, much less than in the 
diffuse form of the disease, for in Tornwaldt's disease the source of 
the discharge is from an adventitious cavity, while in the diffuse 
form the secreting surface involves the whole posterior wall of the 
naso-pharynx, extending from one Eustachian tube to the other. As 
the result of the more or less complete closure of the orifice of the 
bursa, we have, in a certain proportion of cases, the formation of a 
retention cyst, a condition which Tornwaldt found in forty -five out of 
two hundred and two cases of bursal disease. Similar cases have 
been reported by Zahn, Troeltsch, and Czermak. 

I have removed, by means of the curette and snare, small masses 
of the diseased tissue in the diffuse form of the disease in a number 
of instances. The pathological conditions observed under the micro- 
scope were as follows: the hyperplasia was characterized by the 
bulging of the mucosa, which assumed the form of small raspberry- 
like projections, which gave the vault of the pharynx a somewhat 
mammillated contour. This feature was evidenced by the presence 
of globular protrusions, between which there were furrows of vary- 
ing depths. The lymph tissue was richly supplied with blood 
vessels and a rather dense fibrous connective tissue, the latter hold- 
ing clusters of lymph corpuscles. The lymph follicles were scarce 
and small. In none of the specimens examined was the presence 



NASOPHARYNGEAL CATARRH. 291 

of acinous glands demonstrable. In this feature, therefore, the 
tissue differs essentially from ordinary glandular hyperplasia, in 
which both the lymph tissue and the acinous glands are augmented 
in number and size. 

We are led to the conclusion, therefore, that the increased secretion 
in naso-pharyngeal catarrh has its source largely in the furrows or 
fissures above described, for, as we know, epithelium situated in this 
manner is transformed into mucus much more readily, and with 
greater activity, than when it is located upon the surface. Our 
greatest difficulty in understanding this somewhat curious disease lies 
in the attempt to harmonize clinical observation with the pathological 
changes revealed by the microscope, for, while increased secretion is 
undoubtedly a prominent feature of the disease, the microscope fails 
to reveal the presence of those conditions usually associated with 
hypersecretion, namely, an increase or even the presence of acinous 
glands. We must conclude, therefore, that the increased secretion 
has its source in the fissures which present anatomical conditions not 
unlike ordinary mucous glands, and therefore take on a like func- 
tional activity. In addition to this we must recognize the fact that 
this activity is in no small degree stimulated by the presence of the 
lymphatic follicles. 

Symptomatology. — The prominent symptom of the disease con- 
sists in the discharge from the vault of the pharynx of a thick, yellow, 
muco-purulent discharge, which pours from the glands of the vault 
and makes its way down the pharyngeal Mali into the lower pharynx, 
or, adhering closely to the membrane lining the vault, gives rise to 
more or less irritation. In many cases, the prominent subjective 
symptom of which the patients complain is that of a constant " drop- 
ping" in the throat. The density of the discharge varies greatly at 
different times and in different subjects. In some cases, it is almost 
fluid pus, especially if the source of the discharge is in a bursal cav- 
ity. When it comes, however, from the broadly diffused hyperplas- 
tic glands of the pharyngeal tonsil, it is a thick, grayish-yellow, 
tenacious mucus in all cases. The secretion is constant, accumu- 
lating of course during the night. This nocturnal accumulation 
frequently produces nausea and vomiting. 

As is usual in all cases of chronic inflammatory process in the 
upper air passages, its progress is marked more or less by attacks of 
subacute inflammation, the result of slight exposure to cold, during 
which the symptoms are markedly aggravated for the time. More- 
over, the disease is subject to changes in the weather, the symptoms 
being worse in the fall and spring months, while the summer months 
give more or less complete relief. 



292 DISEASES OF THE NASOPHARYNX. 

It is usually stated that the larynx and the air passages beyond 
are the seat of a mild chronic inflammation ; such a condition I 
believe to be the direct result of a morbid condition of the nasal pas- 
sages, unless, perhaps, the disease of the naso-pharynx gives rise to 
so great obstruction to normal nasal respiration as to compel habitual 
mouth breathing, in which case, sooner or later, laryngeal and 
bronchial trouble will develop. 

Inflammation of the lower pharynx, or of ordinary pharyngitis, is 
not a concomitant of naso-pharyngeal catarrh, although this is a view 
usually taken by most observers. I believe a simple pharyngitis to 
be a somewhat rare affection. It is too much our habit to examine 
the fauces of a patient, and, observing the tonsil slightly red, con- 
gested, relaxed, or flabby perhaps, at once to make a diagnosis of 
pharyngitis without looking for absolute evidence of inflammatory 
action there. The lower pharynx belongs essentially to the food 
tract, and not to the air tract. It is involved sympathetically with 
gastric catarrh, but not, as a rule, with catarrhal disease of the air 
passages. 

Ten cases are reported by Tornwaldt in which headache was a 
prominent symptom, and in which relief was obtained by treatment 
of the naso-pharyngeal trouble. This also we must accept as an in- 
teresting contribution to clinical medicine, as confirming the teach- 
ing first made prominent by Hack, that in every case of cephalalgia a 
thorough inspection of the respiratory tract must be made in order to 
detect any possible source of irritation or diseased action in that re- 
gion. Whereas the relief of this distressing symptom is one of the 
most creditable of our successes in throat practice, there is no spe- 
cial symptom, in any given case of headache, which warrants us in 
the positive assertion that it is dependent on disease of the air pas- 
sages, and yet this distressing disease is relieved, in a large propor- 
tion of cases, by treatment directed to this region. 

It is still a very prevalent impression among otologists and others 
that catarrhal disease of the middle ear is frequently due to a mor- 
bid condition involving the naso-pharynx. Tornwaldt indorses this 
view. Now, while it is an undoubted fact that hypertrophy of the 
pharyngeal tonsil is the cause of ear troubles in young children, in 
the very large majority of cases I think this is due mainly to the fact 
that the pharyngeal space is very largely encroached upon, and its 
normal functions interfered with, by the mere mechanical pressure of 
the hypertrophied lymphatic tissue. In adult life, however, whether 
a naso-pharyngeal catarrh is due to Tornwaldt 's bursa, or to a diffuse 
hypertrophy covering the space, this thickening encroaches so slightly 
upon the pharyngeal cavity that its normal function is but little in- 



NASO- PHARYNGEAL CATARRH. 293 

terfered with. I do not believe that a middle-ear catarrh is ever de- 
pendent on an extension of the catarrhal process from the pharyngeal 
vault. In other words, I think that if we carefully investigate the 
clinical history of these cases we shall find that the catarrhal trouble 
of adult life had its origin in an adenoid during youth, and that this 
was the original cause of the deafness. Tornwaldt asserts that hyper- 
emia and hypertrophy of the nasal mucous membrane, and even a per- 
sistence of nasal polypi, may be the direct result of a nasopharyn- 
geal catarrh, a view in which he is sustained, to a certain degree, by 
Broich and Luc. This assertion I find it exceedingly difficult to 
harmonize in any way with my own clinical observations. That a 
nasal hyperemia or hypertrophy may give rise to a naso-pharyngeal 
catarrh has already been stated. That the converse is true, as a gen- 
eral rule, I find difficult of rational explanation. 

Diagnosis. — The recognition of this disease is based in part on an 
examination of the pharyngeal vault by means of the rhinoscopic mir- 
ror, and in part by the exclusion of disease of the intranasal cavity, 
though in many instances we shall be compelled to depend largely on 
the subjective symptoms. I do not think we can decide in any given 
case that the catarrhal symptoms are directly due to the morbid con- 
dition of the vault of the pharynx until the element of intranasal 
disease has been entirely eliminated. An examination of the pharyn- 
geal vault by means of the rhinoscopic mirror will reveal to us an un- 
broken continuity of smooth membrane. If, however, instead of the 
smooth, rounded, dome-like cavity of the naso-pharynx, we find pro- 
jecting into it from the posterior wall a glandular mass, we have a 
morbid condition characteristic of this disease. There are two con- 
ditions which we recognize in the phaiyngeal vault: one, an en- 
largement of the pharyngeal bursa, and the other, the broad diffuse 
hypertrophy. The latter has already been described. The bursa is 
easily recognized as a rounded, almond-shaped projection in the me- 
dian line, and about midway between the prominence of the atlas and 
the dome of the pharynx. The noticeable condition that is charac- 
teristic of both forms of naso-pharyngeal disease is the large amount 
of thick inspissated muco-pus which is found in this cavity. The 
diagnosis of this disease is ordinarily easy, as based on the direct 
inspection. The symptoms, however, should always aid us, the 
dropping of mucus from the pharyngeal vault being characteristic 
of the disease, even when based on subjective symptoms alone. 
Syphilitic disease, resulting in .ulceration and necrosis, may occa- 
sionally give rise to a profuse discharge of pus, but in these cases 
the syphilitic diagnosis is simple and a mistake need seldom be 
made. Disease of the accessory sinuses gives rise to a purulent dis- 



294 DISEASES OF THE NASO- PHARYNX. 

charge from the nose, which frequently makes its way into the pharyn- 
geal vault. This pus discharge is largely voided through the anterior 
nares into the handkerchief, and, moreover, a discharge from the 
accessory sinuses is attended by the characteristic fetid-hydrogen 
odor, which is never present in any form of catarrhal disease of the 
naso-pharynx. 

Peognosis. — This disease involves no dangerous tendencies, and 
shows no very marked disposition to increase, although it is essen- 
tially a chronic affection, and, moreover, shows no tendency whatever 
to a spontaneous cure. The prognosis as regards cure must be based 
mainly on our special skill in removing the definite morbid lesion 
which our examination shows us to be present. In the present state 
of our knowledge of disease of the upper air passages, I think we are 
justified in assuring our patients of a complete relief from all the 
troublesome symptoms. For, in the very large majority of cases, 
the disease can be cured, provided the patients are willing to submit 
to the long-continued course of treatment often required. 

Tkeatment. — I am disposed to question the efficacy of internal 
medication in naso-pharyngeal catarrh as has been suggested by Bev- 
erley Robinson, Moure, and others, though if there is a gouty or 
rheumatic habit, there can be no question that a cure will be facilitated 
by the administration of gouty and rheumatic remedies ; and yet my 
own clinical experience does not justify the claim that a cure can be 
accomplished by those measures alone. General hygienic measures 
are of the utmost importance: the regulation of the clothing, the 
habits of life, attention to the skin, bathing, etc., such as have already 
been discussed in the chapter on taking cold. Robinson, in a num- 
ber of communications on this subject, has advocated, with a consid- 
erable degree of enthusiasm, the internal administration of cubebs, 
as possessing specific properties in the treatment of this disease. 
As I understand it, he does not positively state that it cures, but 
rather that it ameliorates the severity of the symptoms. Its action, 
I take it, is simply as a stimulant, by which a freer and more fluid 
secretion of mucus is excited from the glancluar structures in the 
pharyngeal vault. Alcohol and tobacco undoubtedly aggravate an 
existing naso-pharyngeal catarrh, and should be interdicted. The 
practice has come into vogue of late years of treating catarrh at our 
prominent spas, both in this country and abroad, by the internal 
administration of mineral waters, combined with their local applica- 
tion by means of atomizers and douches. I have never seen any no- 
table good results accomplished by these methods. Robinson and 
Moure both claim that those mineral waters which contain a large 
proportion of sulphur are of special advantage in the treatment of 



NASO-PHARYNGEAL CATARRH. 295 

this disease. I see no objection to their use, as most of our patients 
are benefited by the use of a mild alterative and laxative mineral 
water. Too great reliance, however, should not be placed on this 
method of treatment. Climatic influences are very marked, in this 
as in all forms of catarrhal disease, but the change of residence af- 
fords only temporary relief, and the symptoms all return, as soon as 
the patient is subjected again to the influence of cold and damp at- 
mospheric conditions. 

The radical cure of the disease depends, I think, altogether on 
certain local measures, applied directly to the seat of the disease. 
Astringent washes and douches, in this form of the disease, not only 
exert a palliative influence, but also exercise certain curative powers. 
If the muco-pus be thoroughly removed twice each day, the symp- 
toms are mitigated, and the character of the discharge improved. 
For this purpose, any lotion which dissolves mucus and controls cell 
proliferation may be used, as : 

I^ Acidi carbolici, gr. iij. 

Pot. cblorat., 3 i. 

Glycerini, 3 i. 

Aquae, ad \ vi. 

M. 

1$ Zinci sulpho-carb., gr. iij. 

Acidi salicylici, 3 i- 

Aqua? 3 vi. 

M. 

1$ Potass, permanganat 3 ss. 

Aquae ; vi. 

M. 

The pharyngeal vault cannot be reached through the nasal passages 
by means of atomizers in such a way as to admit of thoroughly re- 
moving the mucus which lodges there. The ordinary nasal douche 
answers a fairly good purpose, although by far the best device for a 
thorough cleansing of the pharyngeal vault is the post-nasal syringe 
shown in Fig. 15. 

Kadical measures, however, are demanded if the disease is to be 
really cured. Many patients may object to the cautery, or to sur- 
gical interference, and in these cases a certain amount of reliance can 
be placed on the local application of strong drugs. After thoroughly 
cleansing the part, the officinal glycerole of tannin, or, better still, the 
officinal or the compound tincture of iodine may be used, the appli- 
cation being repeated at intervals of from three days to a week, or a 
solution of nitrate of silver, twenty to thirty grains to the ounce. The 
acetic-acid preparations seem to possess a special action on this form 



296 



DISEASES OF THE NASO-PHARYNX. 



of hypertrophy, preference being given to the monochloracetic acid, 
in its undiluted form. Lactic acid, also, is worthy of trial, and may 
be used in a solution of from thirty to sixty grains to the ounce. 

In making these applications, it is necessary to avoid touching 
healthy parts ; hence the palate should be controlled by means of the 
palate hook, or, better still, it should be tied back by means of a rub- 
ber cord. A very simple procedure by which this measure, which is 
often unpleasant to the patients, may be avoided, is to make use of 
a cotton pledget, twisted firmly on the end of a bent probe, the 
pledget being made sufficiently large to enable the operator to coat 
its posterior aspect only with the agent to be used. A simple little 




Fig. 52.— Author's Porte-Caustique for Pharyngeal Vault. 

instrument for making strong applications is shown in Fig. 52. In 
the cup may be fused chromic acid preferably, or perhaps nitrate of 
silver, and this is carried to the vault of the pharynx, when the cup 
holding the caustic is protruded from the tube by pressing upon a 
button at the proximal end, and, after sweeping it over the part to be 
medicated, is withdrawn into the enlarged distal end of the tube, 
when the instrument is easily removed without injuring healthy parts. 
The above simpler measures of local application involve a some- 
what prolonged course of treatment, and one in which the ultimate 
success is not of a most satisfactory character. As before stated, the 
radical cure of the disease demands the thorough destruction of the 
offending tissues. Where Tornwaldt's bursa exists, probably the 
best device for its destruction is in the measure advocated by Torn- 



NASOPHARYNGEAL CATARRH. 297 

waldt himself, wliicli consists in the use of the galvano-cautery elec- 
trode. For this purpose he uses a pointed platinum tip, which is 
to be inserted directly into the opening of the bursa. Tornwaldt 
claims, that if thoroughly done one application is usually sufficient, 
though in most cases repeated applications will be required. 

In some cases, Tornwaldt injected the bursa with a ten-per-cent 
solution of nitrate of silver, making use of a small syringe with a 
long curved platinum tube, the end of which was inserted directly 
into the bursal orifice. In other cases, pure nitrate of silver was 
fused upon the end of a r^robe, and passed into the bursa, although 
his results were not so good as with the galvano-cautery electrode. 
Broich, on the other hand, depended almost exclusively on the in- 
jection of nitrate of silver, abandoning the use of the galvano-cau- 
tery on account of the intense reaction producing violent occipital 
and cervical pains which seemed to follow. When the orifice of 
the bursa cannot be seen, the electrode is simply to be forced di- 
rectly through the wall, without reference to a normal opening, and 
the cavity opened up in its long diameter. This closed condition 
may be the result of morbid action, or there may be a congenital 
cyst, as in the case reported by Lehinann, in which the cyst was ex- 
tirpated by means of a pair of curved scissors. In those cases in 
which the catarrh is dependent upon a broad, flat, diffuse thickening 
of the glandular structures in the pharyngeal vault, the glandular tis- 
sue should be destroyed, and for this purpose we use one of the ap- 
plications already noticed, by means of the little instrument shown 
in Fig. 52, giving preference to the chromic acid. If these measures 
fail, however, we resort to the more powerful action of the galvano- 
cautery. In this, as in all measures, the part should be thoroughly 
cleansed first, by the use of the syringe, in order to remove all the 
adherent muco-pus, after which, the palate being held well under 
control by means of the retractors or cords, the electrode is passed 
well up to the upper border of the gland structures, somewhat to one 
side of the median line, when, the circuit being closed, it is drawn 
down in a vertical line, to a point perhaps a quarter of an inch above 
the promontory of the atlas, after which, if the patient tolerates the 
manipulation, a second and parallel furrow may be made on the other 
side. The electrode to be used in this manipulation may be the or- 
dinary knife-shaped electrode bent to the proper angle, or, as better 
protecting the soft parts, there may be used the instrument shown in 
Fig. 55, in which, as will be seen, the tip is formed by a spiral wire, 
covered with a hood. Where the manipulation behind the palate is 
not feasible, the pharynx may be reached directly through the nose 
by the instrument shown in Fig. 53, in which the transverse wire 



298 DISEASES OF THE NASOPHARYNX. 

across the end of the electrode constitutes the cauterizing part. It 
can be used on both sides at the same sitting, the cauterization being 
repeated at the end of a week. After the operation the douche or 
spray should be again used, in order to cool the part and control any 



Fig. 53.— Electrode for the Naso-pharynx, to be manipulated through the Nasal Passages. 

tendency to inflammatory reaction. In addition to this, the patient 
himself should be directed to use the douche twice daily, after the 
manner already indicated, and report for treatment at the end of a 
week, when the same procedure may be repeated. As Broich dis- 
covered, the galvano-cautery, even in the pharyngeal vault, is often 
attended with bad effects, inflammatory reaction, neuralgia, etc., and 
must be used with the greatest possible care. The treatment of these 
cases of broadly diffused thickening with the cautery is sometimes 
very unsatisfactory. In such cases the curette shown in Fig. 58 is 
very useful. The pharyngeal vault is not so easily anesthetized with 
cocaine as is the membrane lining the nasal cavity, but no operation 
should be attempted in this region, without first making a thorough 
application of a twenty-per-cent solution of this drug, allowing from 
five to eight minutes to elapse before operative procedure. 



CHAPTER XLII. 

HYPEETEOPHY OF THE PHAEYNGEAL TONSIL, OE ADE- 
NOID GEOWTHS IN THE VAULT OF THE PHAEYNX. 

This term is used as more accurately describing that condition of 
glandular hypertrophy in the upper pharynx, which has usually 
been described under the term adenoid vegetations. It may be de- 
fined as a true hypertrophy of the normal lymphoid structures found 
in the pharyngeal vault, whose existence has been recognized since 
the days of William Hunter. 

Etiology. — The disease is essentially one of child life, develop- 
ing in infancy, and probably in some cases congenital. Like other 
glandular hypertrophies, these growths show a tendency to appar- 
ently disappear at puberty. The question arises here, how far any 
general dyscrasia, such as scrofula, syphilis, or tuberculosis, may 
predispose to this disease. 

Lowenberg states that the lymphatic temperament is the " cause 
of the disease in the very large majority of the cases which he has 
seen." Lowenberg apparently holds that there is a scrofulous taint 
in these cases; Meyer and all subsequent writers reject this theory. 
These growths I think may be considered as the result simply of in- 
flammatory changes in the lining membrane of the upper air passages 
and their appendages under the stimulus of repeated colds, as for- 
merly stated by myself. It occuis in children more frequently than 
in adults, for the reason that glandular structures in children are 
more prone to take on morbid changes. The local inflammatory 
changes in the region of the fauces which accompany eruptive fevers 
in children frequently prove a starting-point for changes which re- 
sult in hypertrophy of the pharyngeal tonsil, or stimulate into a 
renewed activity an already existing growth in this region. 

Heredity has an undoubted influence. We frequently see a num- 
ber of children in the same family affected. Out of 102 cases re- 
ported by Meyer, 52 were males and 50 females, but of those over 
fifteen years of age, the larger proportion was females. Of my own 
cases, 49 were females, and 26 males. 21 being under fifteen and 54 
above that age. 



300 DISEASES OF THE NASO- PHARYNX. 

In a large proportion of cases in which I have seen it, less than half 
showed any morbid condition in any portion of the nasal passages. 
It is frequently associated with hypertrophic rhinitis. In ten of my 
seventy -five cases there was marked enlargement of the faucial ton- 
sils, and in a much larger number moderate enlargement of these 
glands. In four cases atrophic rhinitis was present, three of these 
having reached the stage of ozaena. 

Pathology. — A microscopical examination of the pharyngeal ton- 
sil shows its construction to be as follows : 

First, it is covered by a layer of columnar ciliated epithelium 
which exhibits the features of stratified columnar epithelium. The 
single columnar cells vary greatly in height, and exhibit sometimes 
long, sometimes short, bent ciliee. Between the elongated feet of the 
epithelial cells irregular corpuscles of varying shape are visible, such 
as occur throughout the mucous layer of the aerial passages, the 
larynx, the trachea, and the bronchi. Only in one specimen was one 
side of the tumor covered by a narrow layer of stratified epithelium, 
probably corresponding to the medial aspect of the tumor, without 
cilia, with a gradual transition into columnar epithelium. 

Second, all the tumors exhibit a lobate appearance, the fissure be- 
tween the lobes being sometimes shallow and at other times very 
deep, dividing the whole mass into a number of longitudinal ridges. 
Each ridge may again exhibit a varying number of shallow papillary 
protrusions. Under the microscope correspondingly we observe large 
protrusions, which are caused b} r the follicular formation of the tis- 
sue, and small ridges of a papillary aspect caused by narrow protru- 
sions of the subjacent tissue. 

Third, the main mass of the tumors is composed of lymph tissue, 
formerly termed adenoid tissue, from the mistaken idea than this tis- 
sue is glandular in nature. No epithelial formations enter, however, 
the structure of the tumor, save the depressions and furrows between 
the lobes, sometimes penetrating very deeply into the mass of the 
tissue, and there producing manifold secondary convolutions. Be- 
neath the epithelial cover there is no fibrous connective tissue around 
the lobes, while the papillary elevations are produced by a delicate 
fibrous connective tissue freely supplied with lymph corpuscles. 

According to the general structure of lymph follicles and lymph 
ganglia, we find in the tumors under consideration a varying number 
of lymph follicles, consisting of an accumulation of lymph corpuscles, 
and supplied with a comparatively small number of blood-vessels. 
The follicles are separated from each other and inclosed by what is 
known as inter-follicular strings. In these both a myxomatous reticu- 
lum and the fibrous varietv of the connective tissue are more developed 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 301 

than in the follicles, and the blood-vessels are somewhat more numer- 
ous. Only in one of the specimens was there a marked fibrous intra- 
follicular tissue with comparatively few lymph corpuscles. In all 
others the fibrous connective tissue was but little developed, which 
feature would account for the comparative softness of these new for- 
mations. 

With high power of the microscope, in all specimens the features 
common to lymph tissue are discernible. There is a myxomatous 
reticulum ill-defined and crowded with lymph corpuscles, in the 
meshes within the follicles. There is a more developed myxomatous 
or fibrous reticulum, with comparatively fewer lymph corpuscles in 
its meshes within the inter-follicular strings. 

The examination proves that the formations under consideration 
are not tumors, in the proper sense of the word, but a hyperplasia of 
the lymph tissue which constitutes the so-called pharyngeal tonsil. 
All writers regard the morbid process which results in this form of 
growth as one of true hypertrophy, except TYoakes. 

In connection with the disease in the pharyngeal vault, we often 
find a chain of enlarged follicles, extending down on either side of the 
lower pharynx, immediately below the posterior pillars of the fauces, 
and a large number of scattered follicles over the pharyngeal surface, 
both in a state of enlargement and constituting a chronic follicular 
pharyngitis, or what is often called pharyngitis granulosa. L6 wen- 
berg regards this as a primary stage of glandular enlargement in the 
pharynx, which extends to the tissues above, while Eoe makes the 
point that while the disease of the lower pharynx is an hypertrophy 
of the normal glands, that in the pharyngeal vault is characterized 
h\ an involvement of all the normal elements of the mucous mem- 
brane. We have already shown that the disease process in the 
upper pharynx involves mainly the lymphatic structures, the connec- 
tive-tissue element playing but a very small part in the process. 
Hence we may safely say that the disease of the two regions is iden- 
tical. Further, my own observation goes to show that they develop 
together. Follicular pharyngitis is an exceedingly common affection 
in childhood, and I think we rarely meet with a case in which the 
glands of the vault of the pharynx are not notably involved. 

Symptomatology. — The prominent and most troublesome symptom 
to which the presence of these growths gives rise is an excessive dis- 
charge of mucus or muco-pus. The source of the discharge is in the 
diseased glands themselves, their normal secretory function being 
greatly increased, in the manner already discussed in connection with 
the pathology of naso-pharyngeal catarrh. In those cases in which 
the growth has attained a large size, the discharge makes its way 



302 DISEASES OF THE NASO-PHARYNX. 

through the nasal cavities proper and is voided through the nostrils. 
It is a thick, ropy, tenacious mucus, which tends to accumulate in the 
nares, especially in young children, from which it is expelled with 
difficulty. 

Another symptom which may be traced directly to the existence of 
these growths is the altered character of the voice. This is changed 
into what Meyer calls the dead voice. It is the voice of one with a 
cold in the head ; that is, the nasal twang is more or less completely 
abolished. In this way "m" and "n" become "eb" and "ed." 

In Meyer's original paper, prominence was given to the occurrence 
of ear symptoms in connection with adenoid disease. No symptom 
of the disease possesses greater importance, or requires more thorough 
appreciation and study, than that of ear complications, occurring, as 
they do, early in life, and at a time when only their prompt recogni- 
tion may save the patient from permanent loss of hearing. The pro- 
portion of cases which escape ear-trouble is small. The two aural 
conditions met with in adenoid disease are chronic catarrhal otitis 
and chronic purulent otitis. The method of development of these two 
diseases I believe to be essentially the same. It is usually stated that 
ear disease from the presence of adenoid growths in the pharyngeal 
vault is due to pressure on the Eustachian orihce. These growths are 
of a soft, pulpy consistency, while the eminences which surround the 
Eustachian orifice are hard and dense; hence, any pressure exerted 
upon them by an adenoid growth would have but slight if any effect. 
I think a far more plausible explanation of the symptoms is in the 
interference with the renewal of air in the middle chamber, caused by 
their presence in the pharynx. Any cause which interferes with free 
nasal respiration, if continued sufficiently long, is liable to cause im- 
paired hearing, by its interference with this function. Moreover, 
the free action of the levator palati muscles is interfered with by the 
presence of these growths, and this movement is of the utmost im- 
portance in accomplishing this mechanism of air renewal. In study- 
ing these parts by the rhinoscope, the impression is gained that the 
tendency of muscular movement here is to force air into the middle 
ear. 

As a result, then, of this interference with the normal respiration, 
rarefaction of air gives rise to a condition of hyperemia of the mu- 
cous membrane extending through the Eustachian tube and middle 
ear. Now, this hyperemia does not constitute inflammation. In- 
flammation, as I take it, is attended with hypersecretion. Hyper- 
secretion is not always a feature of chronic catarrhal otitis media, 
so-called. The Eustachian orifice is closed, the air in the middle 
chamber rarefied, the drumhead retracted, and further changes in 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 303 

connection with the more intricate apparatus of the ear result in im- 
pairment of function. In a very large number of cases this process 
continues, leading to ankylosis of the ossicles and atrophy of the 
tympanic membrane. In the smaller proportion of cases, arising 
in the same manner from nasal stenosis and rarefaction of air in the 
middle chamber, we have set up a , true catarrhal inflammation with 
hypersecretion. Now, as an invariable law, when we have catarrhal 
inflammation setting up in a closed cavity, this process is converted 
into one of suppuration. As the result we have a chronic suppura- 
tive otitis media. Why this occurs in one case and not in the other 
I do not know. 

That the ear symptoms are due to an extension of catarrhal inflam- 
mation to the Eustachian tube I think is very questionable. Cer- 
tainly it is very rare to find the lining membrane of the Eustachian 
orifice in a condition showing any evidence of catarrhal inflammation 
by rhinoscopic examination. Mechanical obstruction is an active, 
although not the most prominent, agent in the development of these 
symptoms. 

Nasal stenosis is quite a prominent symptom of the affection, and 
is present even in cases in which the growth has not attained an un- 
usual size. 

It is a very noticeable fact that these growths vary in size at dif- 
ferent times, under the influence of damp weather or other causes. 
This occurrence, especially in children, is attended with an increase 
of secretion, with obstruction to nasal breathing ; in fact, the child 
has apparently an ordinary cold in the head. We must bear in mind 
that acute rhinitis is comparatively rarely met with in a child, and 
that in such cases it is really suffering from a subacute inflammation 
of the phaiwngeal tonsil. In other words, the clinical history of 
chronic inflammation or hypertrophy of the pharyngeal tonsil is 
marked, like inflammatory processes in other portions of the upper 
air tract, by a liability to repeated attacks of acute inflammation. 

Cough is present in certain cases, caused by the secretion, or by 
the habitual mouth breathing. 

Headache is an occasional symptom, not perhaps occurring with 
the same frequency as in hypertrophic rhinitis. It probably arises 
in much the same manner as do those cases which depend on dis- 
ease of the nasal chambers. 

Asthma, also, may be dependent on the existence of adenoid 
growths, as noted by Frankel and Chatellier. One such case has 
come under my own observation, in which complete cure was ob- 
tained by the removal of the growth. 

Chatellier mentions nightmare as a symptom of the disease. 



304 



DISEASES OF THE NASO- PHARYNX. 



This symptom is rather an accompaniment of enlarged tonsils, a dis- 
ease in which it occurs quite frequently. I should be disposed to 
attribute it to the enlargement of the faucial tonsils, which so fre- 
quently accompanies the affection under discussion. Snoring, on the 
other hand, is almost always present in disease of the pharyngeal 
vault, due probably to a certain amount of relaxation or weakness of 
the palatal supports, which accompanies the disease. In very young 
children, the inability to nurse, the result of nasal stenosis from this 
or any other cause, is well known. Spasm of the glottis, also, in 
children of neurotic habit, may be a very troublesome symptom of 
the disease. 

Both Hooper and Chatellier mention night sweats as one of the 

symptoms of the disease. This 
symptom is present in a certain pro- 
portion of cases, but probably only 
in those whose general health is 
poor. 

Probably no symptom of adenoid 
disease is more striking than the 
peculiar facial appearance which 
these patients present. This ap- 
pearance, is, however, most notice- 
able in children under the age of 
fifteen or sixteen years, but it is so 
marked in these young people that 
in the majority of cases a glance at 
the patient is sufficient for a correct 
diagnosis. This peculiar facial ex- 
pression consists essentially in a 
broadening and flattening of the 
Now, add to this the open mouth, 
usually rendered necessary by the nasal stenosis, and you will give 
to the child a curiously vacant, semi-idiotic look, which is very 
striking (see Fig. 54). 

I think that ordinarily the essential feature of the facial expres- 
sion lies at the root of the nose, in its broadened and flattened con- 
tour, by which there is apparently a widening of the distance between 
the two eyes. The idiotic expression is perhaps fanciful, for the 
mere opening of the mouth and depression of the jaw gives that, al- 
though the dull expression is undoubtedly enhanced by the impair- 
ment of hearing, which so frequently exists in these cases. In my 
own experience, I have never been able to discover that these patients 
were not the possessors of the ordinary brightness and alertness of 




:vV»*;-l" ■-W'V.--;<i\{.-\ ■■■■■•'■ -'-^-M 4 '\\ 



Fig. 54. —The Face of a Girl Illustrating the 
Peculiar Facial Expression which is Char 
acteristic of the Existence of an Hyper- 
trophied Pharyngeal Tonsil. (Hooper.) 

bridge and root of the nose. 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 305 

intellect of children in ordinary health. That there is any morbid 
development of the facial bones, as suggested by David, becomes ques- 
tionable, when we remember how rapidly all these conditions disap- 
pear after the removal of the growths, as do also the other symp- 
toms alluded to, such as mental apathy, inattention, etc. When the 
growths are large and nasal stenosis is marked, the sense of smell is 
necessarily impaired, from the imperfect manner in which odorous 
particles reach the terminal filaments of the olfactory nerve. The 
sense of taste also is impaired, as is usually the case when the sense 
of smell is defective. 

Diagnosis. — The prominent symptoms of facial expression, dead 
voice, nasal stenosis, and catarrhal discharge will ordinarily prove 
sufficient for a correct diagnosis. Examination, however, by the 
rhinoscopic mirror gives always the additional information of the 
size of the growth. By anterior examination nothing will be learned 
ordinarily, other than the absence of a diseased condition of the nasal 
cavity, to account for the trouble. By posterior rhinoscorjy, instead 
of the rounded dome-like cavity of the pharynx, there will be pre- 
sented a rounded mass of a reddish-gray tinge, with a mammillated 
surface, hanging down, as it were, and obstructing the view into the 
nasal cavities. I think the best test for the existence of an adenoid 
growth is to trace the continuity of the pharyngeal wall, by inclin- 
ing the mirror slowly forward, in such a way as to bring progres- 
sively into the field of vision the posterior wall of the pharynx, 
gradually passing over to the broad expanded upper portion of the 
nasal septum, and tracing its converging lines until it reaches the 
palate. If in this inspection we find the view of the upper portion of 
the nasal septum obstructed in a greater or less degree, we recognize 
the presence of a growth whose uniform contour and symmetrical 
appearance will indicate hypertrophy of the normal tissues or an 
adenoid growth. In tracing the continuity of smooth surface from 
the pharynx to the septum, we will find that even a comparatively 
small growth will interrupt the view and shadow the broad upper 
portion of the nasal septum. The size of the growth will be esti- 
mated by the extent to which the nasal septum is veiled on inspection 
by the pendent growth. 

In adult life the growth presents a smoother contour, the fissures 
having to an extent disappeared. The location of the growth does 
not, I think, vary greatly in different cases. It constitutes, in mild 
cases, a broad ridge extending across from one Eustachian tube to the 
other. If the tumor is of larger size, the centre of this ridge becomes 
enlarged and rounded, and Tjrojects farther downward and forward 
toward the soft palate. Mever describes these growths as being 
20 



306 DISEASES OF THE NASO-PHARYNX. 

found both in the fornix, or upper portion of the pharynx, and on the 
posterior or lateral walls of the upper pharynx, and very rarely on 
the floor of the nares, where they form, as it were, a duplicature of 
the soft palate. He also describes hard round spots on the velum 
which he considers of an identical nature. 

The lower pharynx presents no distinctive appearances in these 
cases, although it is an almost invariable rule that there is chronic 
follicular pharyngitis with more or less purulent secretion, whose 
source is in the diseased condition of the pharyngeal vault. 

All observers recommend a digital exploration of the pharyngeal 
vault as an additional aid to diagnosis. This is not a difficult manip- 
ulation, and is generally fairly well tolerated by children, and yet I 
think is rarely necessary. Very little information is gained thereby 
which is not already obtained by the subjective symptoms and rhino- 
scopic examination ; although, when rhinoscopy is impracticable this 
should be always resorted to, as giving us information not only of the 
presence of the growth, but also of its size and character. Lennox 
Browne makes an excellent suggestion on the carrying out of this 
manipulation, which is that when the finger has reached the pharnyx, 
the lower portion of the septum should be first sought, and this 
traced up with the tip of the forefinger, until the growth is impinged 
upon, when the exploration of the right and left walls may be com- 
pleted. 

Schech, quoting Semon, advocates as an equivalent for digital ex- 
amination of children, which is occasionally difficult and even pain- 
ful, that the permeability of the naso-pharynx be tested by injecting 
a small quantity of warm water by means of a ball syringe. If the 
water does not at once flow in a stream from the other nostril, but, on 
the contrary, escapes through the mouth, then it is certain that there 
is an obstruction in the naso-pharynx. This method is also recom- 
mended, to prove whether or not an operation has restored the pas- 
sage. This expedient is a most excellent one, and may well be re- 
sorted to before digital exploration is practised. A much better 
method, however, is in the use of fluid cosmolin or sweet oil, atomized 
b}* the instrument shown in Fig. 18. As we know, when this is ato- 
mized it forms a cloud, as it were, of the density of smoke. If this 
is sprayed into one nostril, where the nasal passages and naso-pharynx 
are clear, it will emerge from the opposite side in a stream whose 
force and direction are almost equal to that with which it escapes 
from the tip of the atomizer. If, on the other hand, the naso-pharynx 
is obstructed, the spray emerges from the opposite side in a very 
feeble stream, or even fails to emerge entirely. This is, I think, 
without doubt our best and certainlv our easiest test for the existence 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 307 

of an adenoid growth in the naso-pharynx, and one which I regard as 
almost absolutely diagnostic. 

Prognosis. — The prognosis in these cases is always favorable, as 
regards the entire disappearance of symptoms as the result of treat- 
ment. It has already been stated that there is a tendency at puberty 
for these growths to atrophj r to a certain extent. The question arises, 
then, how far we may be justified in leaving mild cases to the natural 
course, when the development attending upon puberty may be ex- 
pected in the near future. There is undoubtedly an atrophic proc- 
ess which sets in at puberty, but this does not always cause an en- 
tire disappearance of the tumor. The fact that its symptoms are 
markedly ameliorated is probably due in part to the great develop- 
ment which takes place at that age, causing the glandular mass to oc- 
cupy a relatively smaller space in the breathing passages. I think, 
when we consider that the treatment involves no possible risk to the 
patient, and also that the growth is subject to attacks of acute in- 
flammation, by which danger, oftentimes of a serious character, is 
threatened to neighboring organs, that we are rarely justified in 
adopting the expectant course. It should be stated, furthermore, 
that these tumors do not, as a rule, entirely disappear at puberty, 
but in many cases remain as a permanent source of a chronic naso- 
pharyngeal catarrh. 

If serious ear complications have already set in before a case is 
subjected to treatment, I think we may lay it down as a rule, that in 
children a favorable prognosis may be given, not always perhaps as 
to the ultimate restoration of hearing, but certainly to very great im- 
provement. This statement can be safely made with regard to chronic 
catarrhal otitis media. It is also true in suppurative disease, I 
think, with few exceptions. In those cases which have gone on to 
necrosis we all recognize the peculiar obstinacy of the affection with 
which we have to deal, and yet my own experience teaches me that 
we are often warranted in giving a favorable prognosis as regards 
improvement, even here. 

Treatment. — The simpler methods of general medication are 
probably indicated in many of these cases, on account of the impair- 
ment of the general health which is often present. These measures 
embrace simply the administration of cod-liver oil, with general 
tonics. My own preference is decidedly in favor of cod-liver oil, 
when tolerated. In the majority of cases, however, no internal 
medication is indicated. 

The question as to the value of local treatment by means of 
douches and sprays is rather an interesting one. In the majority of 
ordinary catarrhal affections of the upper air passages, the use of 



308 



DISEASES OF THE NASO-PHARYNX. 



astringent sprays is attended with very little, if any, permanent bene- 
fit. In glandular enlargements, however, of the kind under discus- 
sion, especially when we consider their very soft consistency and 
low grade of organization, the use of astringents is attended, often- 
times, with the best of results, both in limiting the amount of secre- 
tion and in securing an absolute reduction in the size of the growth. 
This, however, is all that is accomplished. A cure cannot be looked 
for unless in the very early stages of the disease, when the growth 
has attained but a limited size. Furthermore, I think much can be 
accomplished by the use of astringents in preventing the frequent re- 
currence of attacks of acute inflammation, to which those suffering 
from the disease are so liable. The only form of medication, prob- 
ably, adapted to the disease is that of a watery solution. A well- 
grounded prejudice exists against the use of the Thudicum nasal 
douche in adenoid disease. There is no doubt that mischief may 
be done by the use of this device, and now that the ingenuity of our 
instrument makers has placed in our hands so many and such effi- 
cient hand-ball atomizers at a moderate price, preference should 
always be given to the spray, as a means of local application, over 
every other device. We give preference then to the instrument shown 
in Fig. 18. Probably no better astringent can be used in these cases 
than tannin. My own custom is to prescribe this in the following 
combination : 



1$ Acidi carbolici, 
Acidi tannici, 
Sodii biborat., 
Glycerini, . 
Aquae, 



gr. l. 
gr. xl. 



gr. xx. 

Iss. 
ad 1 iv. 



This is to be applied twice daily at home. One of the most 
troublesome features of the disease is the large accumulation of 
mucus in the nasal cavities and the difficulty the child experiences in 
expelling it. The above lotion is cleansing, disinfectant, and astrin- 
gent, and, being thoroughly applied at the hands of the mother or at- 
tendant, fulfils well these three indications. 

As before stated, all that can be expected by local medication is 
a modification of the symptoms. A radical cure is dependent upon a 
thorough extirpation of the offending glands. This must be accom- 
plished either by destructive agents, such as the chemical or potential 
cautery, or by the snare or cutting instruments. Owing to the pre- 
judice against surgical operations in the minds of many people, we 
will occasionally be compelled to resort to destructive agents for the 
removal of these growths, although in all cases, I may state here, the 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 309 

complete extirpation by an operation is the preferable mode of pro- 
cedure. The use of caustics is attended undoubtedly with successful 
results, although it involves a long course of treatment. Here I 
think the galvano-cautery possesses a destructive power which is far 
more active than are chemical agents, and is always to be preferred. 




Fig. 55.— Author"s Electrode Fitted with a Shield for use in the Pharyngeal Vault. 

The manipulation by which this is accomplished is quite simple. 
The only risk to be avoided is of burning the soft parts. The elec- 
trode shown in Fig. 55, it will be noticed, is fitted with a hood in 
such a manner as to thoroughly protect the palate from injury in 
withdrawing the instrument. In small children it is not always 
feasible to introduce the curved electrode behind the palate, hence we 
are compelled to introduce the instrument through the nasal pas- 
sages. If introduced in this manner, the platinum tip will usually 
strike the central portion of the mass, and a considerable destruction 
of tissue may thus be accomplished. Moreover, there is abundant 
room for a vertical movement to be permitted in this manipulation, 
by which successive portions of the growth may be subjected to cau- 
terization. The electrodes by which this is accomplished are shown 
in Fig. 56. In the absence of the cautery battery, chemical agents 
must be used. Of these, I should give preference to chromic acid 
fused on the end of a properly shaped applicator, which may be 




Fig. 56.— Straight Electrodes for the Application of the Galvano-cautery to the Pharyngeal Ton- 
sil, through the Nasal Cavity. 

arranged in the same manner, with a protecting hood, as the electrode 
already mentioned, or the applicator may be concealed in a tube, as 
shown in Fig. 52, and protruded after the instrument has been 
passed into the pharyngeal vault. Manipulation through the lower 
pharynx is not always tolerated by young children, and in a number 



310 DISEASES OF THE NASOPHARYNX. 

of cases in which the nasal passages have admitted of it I have made 
the application directly through the nares, the applicator being pro- 
tected by a small slender tube and protruded after this has been 
passed through the nasal cavities. Lowenberg prefers nitrate of 
silver. 

As already stated, the complete extirpation of these growths by a 
surgical operation should always be resorted to, in preference to any 
other measures. Most observers who have written on the subject of 
adenoid growths have presented instruments and methods of their 
own devising for the accomplishing of this end. Meyer uses a ring- 
knife, consisting of a small transverse oval ring with one sharp 
though not absolutely cutting edge. The patient being seated with 
the mouth gag firmly fixed in position, the ring knife is passed 
through the nose and, its manipulation directed by the left forefinger, 
passed into the vault of the pharynx. In this manner the growths 
are removed as far as possible on that side, when, if necessary, the 




Fig. 57.— Lowenberg's Forceps. 

knife is transferred to the other nostril and the remainder of the 
tumor extirpated. Where there are portions left on the lateral walls 
of the upper pharynx, he completes the operation by means of an 
instrument not unlike a lithotrite. To prevent recurrence, he advises 
a weekly application of the mitigated stick of nitrate of silver. 

The use of forceps for the removal of these growths was probably 
first suggested by Lowenberg, whose instrument is shown in Fig. 
57. It has a cutting edge on the distal extremity of the blades. Its 
movements are guided by the left forefinger in the pharynx or by the 
rhinoscopic mirror. Cohen recommends the evulsion of the growths 
by a gouge-cutting forceps, modelled after Mackenzie's laryngeal 
forceps. Woakes modifies Lowenberg' s forceps by prolonging the 
cutting edge down on the posterior aspect of the blade, thus adapting 
the instrument to cutting on the posterior wall of the pharynx ; while 
Schech still further modifies Lowenberg' s instrument by prolonging 
the cutting edge completely around the three aspects of the distal ex- 
tremity of the blades. In the above instruments the blades all oper- 
ate transversely in the pharynx. Schutz, however, recommends the 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 311 

use of a forceps with a fenestrated blade operating antero-posteriorly, 
the only advantage of which lies in the fact that in this manner, per- 
haps, the pendulous masses which are occasionally found in the 
upper portion of the vault are more easily seized, while those por- 
tions of the growth which lie more on the posterior wall would 
scarcely be grasped. Major's adenotome is also constructed on this 
principle. The use of a curette naturally suggests itself for the ex- 
tirpation of these growths, as first mentioned, I think, by Lowen- 
berg. His instrument has a sharp cutting edge, and is attached to its 
handle by an S-shaped stem. Victor Lange indorses this method of 
operation, while Chatellier considers it a rather dangerous operation. 
Frankel advises it only in cases in which the growths are not to be 
reached with the forceps. This instrument is undoubtedly available 
for use when the growth is small, but is not to be recommended in 
the case of a large growth. It is also useful for the removal of the 
remaining fragments if the main mass has been removed by one of 
the other methods. A form of curette which I make frequent use of 
in this manner is shown in Fig. 58. It consists of an ordinary 
Sims' uterine curette, with the shank bent to the proper angle for in- 
troduction to the pharyngeal vault. Trautmann advises the use of 
a sharp spoon, which is virtually the same device as the curette. 
Guj-e, of Amsterdam, dispensing with all instrumental aid, states 
that the growths can be entirely extirpated by the index finger in- 
serted behind the palate, the process being accomplished partly 
by crushing and partly by scraping with the finger nail. Creswell 
Baber indorses this method, but is entirely correct, I think, in the 
assertion that their complete removal cannot be accomplished in one 
sitting, stating that it should be repeated at intervals of one week, 



Fig. 58.— The Author's Sharp Cutting Curette for the Pharyngeal Vault. 

till the cure is completed, which, as a rule, requires four or five sit- 
tings. In the same category are the methods employed by Dalby and 
Lennox Browne, who make use of a curette, or spoon, attached to a 
thimble, which is fixed upon the end of the forefinger. In this manip- 
ulation, the tip of the finger is left free for exploratory purposes, the 
shaft of the curette being attached to the posterior face of the open 
thimble. Michael, of Hamburg, has devised a rather ingenious in- 
strument, which somewhat resembles Woakes' forceps, excepting 
that the blade of the instrument shows a more extended curve, while 



312 



DISEASES OF THE NASO- PHARYNX. 



the hollow of the instrument extends the whole length of the curved 
portion of the blade, which is of uniform breadth and presents a 
sharp cutting edge. In addition to this, the shafts of the instrument 
curve outward, in such a manner as to allow the uvula to drop 
between them. With various writers advocating different methods 
for extirpating these growths, the question arises, which is the most 
simple and efficient instrument for this purpose? Personally, I have 
always entertained a prejudice against forceps, and most of the writers 




Fig. 59.— Hooper's Instruments for the removal of Hypertrophied Pharyngeal Tonsils. 1, Forceps; 
2, mouth gag; 3, palate retractor. 

who recommend them acknowledge that the operation cannot be com- 
pleted at one sitting ; although Hooper states that the complete ex- 
tirpation of the growth may be done at one sitting by the forceps 
operation, if the patient is put under the influence of an anaesthetic, 
the palate thoroughly retracted, and a mouth gag used. Hemorrhage 
is often produced in forceps operation, and, as Hooper suggests, a 
sufficient time should be permitted to lapse after each introduction 
of the forceps to allow the hemorrhage to cease. In spite of this, 
many cases will be attended with hemorrhage sufficient to interfere 
with this method of operating. Hooper operated with the forceps 
(shown in Fig. 59, 1) , the mouth being held open by a gag, and the 
palate elevated by a Yoltolini hook (Fig. 59, 3). As regards 
Meyer's method of operating, we can only say, in view of the excel- 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 313 

lence of his results, that no better method of procedure can be sug- 
gested, provided one possess the necessary manipulative skill. It 
should be said, however, that it seems somewhat complicated, and at 
the best not an eas}' operation to perform with very young children, 
especially when we consider that one operates without an anaesthetic, 
the patient being fastened to a chair. The method which will com- 
mend itself probably to an unskilled operator, or one not a specialist 
in throat diseases, is either the use of the long-handled curette, or 
Dalbys or Browne's finger curette, or perhaps in a still larger number 
of cases, Guye's suggestion of the unarmed index finger. This oper- 
ation I think should always be done under an anaesthetic, which will 
afford ample time for a fairly thorough disorganization of the growth, 
if not its extirpation. By this method, a complete cure at one sitting 
need never be anticipated. For a rapid removal, without resort to 
anaesthesia, mouth-gags, or palate retractors, I have for a long time 
used a modification of Jarvis' snare, first described some years since, 
and which is shown in Fig. (30. The growth having been observed 
and its size carefully estimated, a loop is formed which will embrace 
it and is then bent forward over the end of the instrument, in order 
to give it a decided kink. The wire is now played out of the snare 
about an eighth of an inch and the whole loop is thrown backward 
toward the handle of the instrument, giving it another bend. As 
.will be seen, it is in a position for easy introduction behind the 
palate, without touching the parts, and may be passed immediately 
to the base of the growth. The palate of course is now immediately 
retracted by reflex irritation, but it should embrace only the tube of 
the snare, without in any degree hampering the manipulation. 

The instrument is now held firmly in place, while the loop is 
rapidly drawn in by turning the screw. As the wire is drawn in, the 
loop is thrown backward with considerable vigor, and embraces and 
severs the growth. In this manner even a broadly sessile growth is 
easily seized and extirpated. There is but trivial hemorrhage, but 
little pain or retching, and the whole manipulation is easily accom- 
plished. After the withdrawal of the -instrument, the tumor is ex- 
pelled through the nose b}' blowing. Occasionally it drops into the 
pharynx below, but this is very rare. In no case has any patient ex- 
perienced the slightest annoyance from the growth dropping too far 
down in the air passages, nor do I regard this as an accident that is 
liable to happen. The operation b}' this method has rarely required an 
anaesthetic, except where the faucial movements prevented the manip- 
ulation. In certain cases in which a post-nasal operation is impos- 
sible, I used an ordinary straight snare through the nose. Having 
mounted the snare with the wire, the loop was bent sharply down 



314 



DISEASES OF THE NASOPHARYNX. 




over the end of the instrument, giving it a kink, and then drawn 
within the tube until only a loop remained sufficiently small to pass 
through the nares ; this was passed vertically until the loop was in 

the pharynx, when the instru- 
ment was turned, bringing the 
loop into a horizontal position, 
with the side undermost toward 
which the larger loop had been bent. The wire 
was now played into the pharynx, when the bend 
which had already been given it threw the loop 
downward, nearly to a right angle. The whole 
instrument was now pressed firmly against the 
pharynx, which, as will be seen, threw the loop 
over the growth. Holding the instrument firmly 
pressed against the pharynx, the screw was rap- 
idly turned and the growth severed. As soon as 
the instrument was withdrawn, the child's head 
was drawn over the table with the face downward 
and the trifling hemorrhage allowed to go on for 
a few moments, when the same manipulation was 
repeated through the nasal cavity of the opposite 
side. After this the child was easily aroused, and 
the masses were expelled by blowing the nose. 

An additional advantage of the use of the snare 
is in the fact that the hemorrhage is less than 
when cutting instruments are resorted to. Hart- 
mann has also recommended the use of a snare 
in which the wire loop is concealed in a stiff ring, 
which enables it to be carried into position before 
it is drawn home. The serre-nceud of Delstanche 
also is a somewhat similar instrument. 

The galvano-cautery snare offers no advantages 
over the cold snare, and is much more difficult of 
manipulation. 

The question of the administration of an anaes- 
thetic is one which every operator will decide for 
himself, in individual cases. In adults, and older 
children, it will rarely be necessary. In young 
children, however, whatever the operation, it will 
be found necessary to administer chloroform or 
ether. If the operation is prolonged, complete ansesthesia will be 
necessary, and, therefore, ether is to be preferred. In the shorter 
operations, by means of a cutting instrument, or my own opera- 




Fig. 60.— The Author's 
Modification of Jar- 
vis 1 Snare - ecraseur 
for the removal of an 
Hypertrophied Phar- 
yngeal Tonsil. 



HYPERTROPHY OF THE PHARYNGEAL TONSIL. 315 

tioii by the snare, complete anaesthesia is not necessary. I have 
always found that a few whiffs of chloroform answer every pur- 
pose. The child will become completely relaxed, and will remain so 
until the operation is completed. In this manner, I think, we incur 
none of the dangers attendant upon the use of chloroform, and, further- 
more, none of the disagreeable features of etherization are encountered. 

My plan is to sprinkle perhaps half a drachm of chloroform on a 
handkerchief, and, seizing the child, surreptitiously as a rule, to hold 
the handkerchief firmly over the mouth and nose, while at the same 
time, the child is drawn down on the lap and held firmly. Primary 
anaesthesia is thus secured, and the operation completed before he is 
aware that anything has been done. In all cases, probably, whether a 
general anaesthetic is used or not, it is wise to apply a ten or twenty per 
cent solution of cocaine, to secure such local anaesthesia as it may 
afford, together with the vascular depletion which attends its use. Of 
course, this will always be used when operating without general anaes- 
thesia, and yet it should be stated that its action upon the glandular hy- 
pertrophies of the pharyngeal vault is very unsatisfactory. It modifies 
possibly the pain of an operation, but does not absolutely control it. 

The question of recurrence has been discussed by most writers, 
and all concur in the statement that complete extirpation is never 
followed by a return of the growth. 

Sequelae. — Hemorrhage very rarely occurs in a degree sufficient 
to demand interference. If such an accident should occur, a tampon 
inserted into the pharyngeal vault is usually sufficient to control it. 
Acute otitis media has been mentioned by Meyer, Frankel, and 
others, as occurring after an operation upon these growths. Frankel 
states that it is more liable to occur after a secondary operation, and 
especially when this is done too soon after the previous sittings. It 
is probably more liable to occur as the result of the use of the curette or 
forceps, on account of injury done to healthy tissues. Another acci- 
dent which attends the operation in a certain proportion of cases is the 
occurrence of a fibrinous exudation on the cut surface, giving rise to an 
ordinary attack of acute follicular disease of the vault of the pharynx, 
extending in many cases to the follicles of the lower pharynx. This is 
accompanied with a rapid pulse, general febrile motion, muscularpains, 
sore throat, painful deglutition, and, indeed, all the local and general 
symptoms of an attack of that disease, and is to be treated in much 
the same manner as the idiopathic affection. This does not ordinarily 
seriously complicate the operation, or interfere with its success, al- 
though in a few instances I have thought that it semed to stimulate the 
tissues to a renewed activity, under which a partial recurrence of the 
growths supervened. I know of no way to prevent this complication. 



CHAPTER XLIII. 

FIBKOMA OF THE NASO-PHARYNX. 

This term is used to designate a form of neoplasm of the naso- 
pharynx which is composed almost purely of fibrous tissue. Spring- 
ing from the basilar process of the occipital bone, and increasing 
by a somewhat slow process of growth, it gradually invades neigh- 
boring cavities, sending prolongations into the nasal passages and 
into the pharynx below, while at the same time it pursues the same 
relentless course as fibroma in the nasal cavity, crowding all the tis- 
sues before it and resulting in absorption of both the soft tissues and 
bony structures which intrude themselves upon its path. 

The tumor is a sessile growth from its onset, and, although occa- 
sionally reported as a naso-pharyngeal polypus, it never assumes the 
gross characteristics of the latter. 

Etiology. — It is difficult to assign any active cause for the de- 
velopment of these growths, in that they arise from tissues showing 
no evidence of morbid activity and in individuals apparently in the 
enjoyment of perfect health. 

In the majority of instances they occur in males, and usually at 
about the age of puberty. In general, these growths occur from the 
ages of fifteen to twenty-five years, while in females the average age 
is slightly greater. 

Symptomatology. — These growths usually manifest themselves 
very early, one of the first symptoms, perhaps, being the occurrence 
of repeated and sometimes profuse attacks of epistaxis. The source 
of this bleeding, in the majority of instances, arises from the blood 
vessels coursing on the surface of the growth itself, the tumor usually 
being exceedingly vascular. Hemorrhage may occur without warn- 
ing. In two instances which came under my own observation, there 
seemed to be a disposition to the occurrence of the epistaxis during 
sleeping hours, the patients being awakened by the choking sensation 
produced by the flow of blood into the air passages. The presence 
of the growth is indicated by a sense of fulness in the naso-pharyn- 
geal region, with a very early impairment of the voice, which assumes 
the characteristics of the " dead voice" observed in connection with 



FIBROMA OF THE NASOPHARYNX. 317 

adenoid disease of this region. As the growth increases there is 
usually bilateral stenosis. 

With the occurrence of stenosis, the peculiar facial expression 
always met with in naso-pharyngeal tumors shows itself. As the 
tumor grows, a genuine facial deformity results ; prolongations of the 
tumor may extend into the nasal cavity, and make their appearance 
externally ; or they may make their way into the accessory sinuses 
and cause additional facial deformity. Exophthalmos may be a later 
S} r mptom, this occurring either as the result of a direct invasion of 
the orbit, or in consequence of the lifting of the orbital plates by the 
pressure of the growth from behind. The occurrence of exophthal- 
mos indicates in the majority of instances the invasion of the antrum, 
although it may be due to an invasion of the ethmoidal cells. 

A certain amount of secretion of a thick, tenacious mucus or muco- 
pus is always present. The normal movements of the fauces are no- 
tably hindered and the secretion tends to become inspissated, and 
thus accumulates in and about the growth and is voided with con- 
siderable difficulty. As the growth extends into the lower pharynx, 
it impinges upon the soft palate, crowding it forward into the mouth, 
not only interfering with the act of deglutition but preventing the 
closure of the palato-pharyngeal space, as a consequence of which 
fluids are liable to be forced into the nasal cavity during the act of 
deglutition. Dyspnoea may occur later in the disease, owing to the 
extension of the growth downward and the mechanical interference 
with the entrance of air into the lungs. 

Pathology. — These tumors are composed almost entirely of dense, 
white fibrous tissue, containing very few if any elastic fibres; their 
minute pathology has been sufficiently described elsewhere. 

The growth is regularly rounded in outline at its onset, while sub- 
sequently its shape is modified by the bony walls of the cavity which 
it invades. The origin of these tumors is probably in all cases from 
the periosteum of the basilar process of the occipital bone, although 
it may in part arise from the body of the sphenoid adjoining. They 
probably spring from a comparatively small area, but as they develop 
their point of attachment increases. The primary origin of the 
tumor is somewhat important, and has been the subject of special in- 
vestigation by Beuf, Brevet, and D'Ornellas, who agree essentially 
with Nelaton that these tumors invariably spring from the base of the 
cranium, and that, where there is an apparent origin from the bodies 
of the vertebra, the wings of the sphenoid, or from the parts lower 
down, it is due either to the burrowing, as it were, or to spreading of 
the original attachment. As the tumor extends to neighboring parts 
and cavities, adventitious attachments are formed. 



318 DISEASES OF THE NASOPHARYNX. 

Diagnosis. — A fibroma can be recognized, even at its onset, by an 
inspection of the vault of the pharynx, by means of a rhinoscopic 
mirror, when it will be seen as a small, irregularly rounded growth, 
of a light pinkish color, springing from the upper portion of the cav- 
ity, the gross appearances of the tumor giving the impression of a 
whitish mass seen through a pinkish veil, and on its surface larger 
blood-vessels may be seen. If the vault of the pharynx is explored 
by the index finger, the tumor will be found hard, dense, resisting, 
and to a certain extent immovable. This manipulation, however, 
should be resorted to with considerable care, in that troublesome 
hemorrhage can easily be excited. 

A fibroid tumor in the upper air passages presents gross appear- 
ances unlike any other form of neoplasm met with in these regions. 
An osteoma can always be recognized as such, by means of the probe 
or the needle. Chondroma is exceedingly rare in the naso-pharynx, 
and presents a decidedly warmer and deeper red color with a yellow- 
ish tinge, is absolutely immovable, manifests no tendency to hemor- 
rhage, and can be subjected to palpation with impunity, and, finally, 
its dense cartilaginous consistency can be determined by -means of 
the needle. Malignant growths present no gross appearances which 
in any way need lead to confusion. The only diagnostic point really 
of importance in this connection is as to the origin of the tumor from 
the nasal cavity proper or from the naso-pharynx, its fibroid charac- 
ter having been recognized. This question is not always easy of de- 
termination when the growth has obtained such proportions as to 
have invaded one or the other of the nasal passages. I am disposed 
to say in this connection that a fibroid tumor which in its incipiency 
produces bilateral stenosis can in the majority of the instances be 
regarded as of basilar origin, while a tumor which produces unilateral 
stenosis early in its development springs from the nasal cavity 
proper. 

Pkognosis. — Naso-pharyngeal fibroma in itself is not necessarily 
a fatal disease, and yet, when we consider the fact that there is no 
limit to its growth, that its progress is oftentimes marked by the oc- 
currence of grave complications, that it may very early in its history 
encroach upon vital parts, and, finally, the very serious character of 
the operations which heretofore have been so frequently resorted to 
for its removal, it becomes an excedingly grave affection. The princi- 
pal complication during the development of the tumor consists of 
the repeated attacks of hemorrhage, which may serve to markedly 
impair the general health, or may even result in a fatal termination. 

Invasion of the cranium, as the result of erosion of the basilar 
process, probably never occurs, but the growth may send a prolonga- 



FIBROMA OF THE NASOPHARYNX. 319 

tion through the foramen lacerum medius. These growths rarely, if 
ever, develop after puberty, but during earlier years their growth is 
somewhat rapid. With the attainment of puberty a notable arrest of 
development is very frequently observed, which may in rare instances 
go still further and result in a retrogressive movement, under which 
a tumor may completely disappear. These growths sometimes, but 
rarely, disappear by sloughing. With the improved methods of our 
own day, by means of which all affections of the upper air passages 
are brought so completely within reach for operative procedure, we 
may undoubtedly look for better results of treatment than used to be 
expected, especially if the somewhat grave operation of resecting the 
superior maxilla is avoided, and it is fairly safe to give a favorable 
opinion in a fairly large proportion of cases. This view is certainly 
justified by the admirable report made by Lincoln, who, in a collation 
of fifty -eight cases, in which seventy -four operations were done, has 
shown us that of these, thirty -eight operations involved opening the 
face by the resection of the superior maxilla. 

Of the thirty-eight severe operations done, but ten cases were 
cured, while with reference to the milder oj)erations the statistics 
are much more favorable. The simpler operations were not done on 
selected cases, and even when the tumor has attained large propor- 
tions and given rise to serious complications, Lincoln's figures 
show that we are warranted in giving a far more favorable prognosis, 
if a milder operation is to be resorted to, than when the patient is to 
be subjected to the additional risk of opening the face. 

Treatment. — The surgeons of ancient times recognized tumors of 
the naso-pharyngeal cavity, and attacked them apparently by much 
the same methods as are often used at present. 

Undoubtedly many cases occur in which, on account of the size of 
the tumor, removal of the superior maxilla will be demanded, yet the 
nicer manipulations which characterize the surgery of the present 
day will enable us successfully to extirpate the neoplasm in a far 
larger proportion of cases than hitherto, with the result of a very 
marked improvement in the percentage of cures. There are a num- 
ber of devices which may be resorted to for the destruction or extir- 
pation of these growths, by which the patient is saved from the 
danger of the radical operation. Barthelemy reports the case of a 
fibroma, completely filling the naso-pharynx and projecting into the 
mouth, which had recurred after a previous operation by incision of 
the soft palate, which was eradicated by injections of a saturated 
solution of chloride of zinc; while in another and very similar 
case, having failed to extirpate the growth by means of the ecraseur, 
forceps, and other methods, he incised the palate, and made injec- 



320 DISEASES OF THE NASO- PHARYNX. 

tions of the same preparation of zinc into the body of the tumor. 
The growth was destroyed by nine injections. Upson also reports 
having successfully treated three cases of naso-pharyngeal growth by 
injections of acetic acid. These results are important as illustrating 
treatment which is exceedingly simple and requires no special manip- 
ulative dexterity. The only objection against it is the length of 
time required, during which the patient is subjected to the presence 
of sloughing tissue, with its resultant fetid discharge and disagree- 
able odor. 

Evulsion is available in cases in which the growth is not very 
large, but it is a harsh method of treatment, attended by great loss of 
blood and liability to injury of soft parts and bony structures. Re- 
currence is apt to take place, and the harshness of the procedure is 
apt to stimulate the tissues to renewed morbid activity. 

The curette is rarely available for growths of the size to which 
these usually attain, although Menocal reports a case successfully 
treated in this manner, access to the growth having been obtained by 
a transverse incision, made with the galvano-cautery knife, through 
the palate. Excision by means of the knife is the most objectionable 
method of treatment and should never be used, because of the violent 
hemorrhage which invariably follows. 

The potential cautery is not to be recommended. 

Electrolysis in the treatment of fibromata of the naso-pharynx 
offers a very ingenious and attractive method of treatment, but it is 
still an unsettled question as to how far this method is successful. 
Cases successfully operated upon by this means have been reported 
and it would really seem that in this measure we have an exceedingly 
feasible means of eradicating these tumors, simple in its application, 
attended with no danger, and ordinarily of little discomfort to the 
patient, and which, therefore, would seem to be especially applicable 
when the general health has become so far impaired as to increase 
the hazard of a radical operation, or even to render it absolutely 
unavailable. Unfortunately, however, we cannot expect these very 
satisfactory results in the use of electrolysis in all cases. This plan 
of treatment is carried out usually by means of long slender needles, 
attached one to the positive and one to the negative pole of a galvanic 
battery of moderate strength. These are thrust deeply into the 
growth, one being inserted into the nasal prolongation, while the 
other is inserted through the mouth. Paquet noticed, in carrying 
out this manipulation, that dry gangrene occurred around the pos- 
itive electrode, while moist gangrene set in about the negative elec- 
trode. Each sitting occupies from ten to twenty minutes and is to be 
repeated in from about five to ten days, according to circumstances. 



FIBROMA OF THE NASO- PHARYNX. 321 

When it is not convenient to insert both electrodes into the mass 
of the growth, the negative electrode may be inserted into the neo- 
plasm, while the positive is attached to a sponge applied to the back 
of the neck. 

Undoubtedly the instrument which is best adapted for the removal 
of the larger proportion of these tumors is the ecraseur in some of 
its forms; and under this term we may include the chain ecraseur, 
the wire-snare ecraseur, and the galvano-cautery loop. This latter 
device was the one so successfully used by Lincoln, and it is the one 
preferred by many operators. The claim that hemorrhage is avoided 
in operations with the galvano-cautery snare is undoubtedly true to 
a certain extent, and yet from a practical point of view it does not 
control hemorrhage to the extent which is claimed. Furthermore, it 
is by no means an easy matter to manipulate this instrument. The 
placing of the soft platinuni wire in position is not a simple proce- 
dure, and even after the pedicle has been grasped by the loop the 
ordinary cautery-handle, with the ecraseur attachment, is a some- 
what bungling instrument to manipulate. Still further, I think 
it has been the experience of most of us in making use of this 
device to find that the platinum wire is very fragile, especially 
when heated to a white heat, and that the operator is not in- 
frequently put to a great annoyance by the breaking of his 
wire, with the result that all the difficult manipulation of putting 
it in place has to be undertaken a second time. It has been re- 
commended by a number of operators to use the steel-wire loop, 
in place of the platinum, in connection with the galvanic battery, 
on the ground that the wire possesses much greater tensile strength, 
is more easily manipulated and put in position on account of its 
rigidity, and that it is quite as easily heated for burning rmrposes 
as the softer metal. 

The cold-wire snare, it seems to me, offers by far the best means 
of dealing with these growths, a strong Jarvis snare with a stout steel 
wire being required. The great advantage of the steel wire, as 
already suggested, is that the loop possesses sufficient rigidity to en- 
able the operator to carry it into the nasal passages, or into the 
pharynx, and force it over the tumor; although, of course, if neces- 
sary, this manipulation can be materially aided by means of the 
finger inserted into the pharynx, where it is designed to embrace the 
growth in that region. Still further, where the growth is of large 
size, and is composed of a number of prolongations or offshoots, it 
is often impossible to engage the whole mass by any device. Hemor- 
rhage, except such as may be excited by the manipulation, may be 
generally avoided, for we may occupv two or three hours, or even 
21 



322 DISEASES OF THE NASOPHARYNX. 

more, if necessary, in separating the mass, thus permanently closing 
the blood-vessels as we proceed. 

Of course, this manipulation is greatly facilitated by the use of 
cocaine, which should be applied as thoroughly as possible, by means 
of the spray or by pledgets of cotton wrapped on a probe. We 
should in all cases endeavor to remove the whole mass at a single 
operation if possible, but when this is not feasible I see no serious 
objection to removing the growth piecemeal, especially when this can 
be accomplished in so simple a manner as that above detailed. After 
all, each operator will select that method of procedure with which he 
is most familiar, and in which he is most skilful, and, while not in- 
tending to entirely condemn the use of the galvano-cautery loop, it 
seems to me that where one has familiarized himself with the manip- 
ulation of the cold-steel wire, he will in most cases find it a pre- 
ferable instrument with which to attack growths in the nose and 
naso-pharynx. The only question which remains to discuss is the 
advisability of measures for the prevention of recurrence. These 
consist essentially in the cauterization of the base, after removal of 
the growth. I know of no statistics bearing directly on this subject, 
and, furthermore, it is one not easy to decide. A majority of oper- 
ators, after removal of the tumor, cauterize the base. I think, how- 
ever, that after the removal of any tumor we should exercise a certain 
amount of conservatism in subjecting healthy tissues to the action of 
caustics, whereby a renewed activity of morbid growth unquestion- 
ably in certain cases is stimulated. Is it not better to carefully watch 
the site of the growth, and be governed in our actions by the appear- 
ances of the stump, and to act only on the appearance of any indica- 
tion of recurrence, being confident that, certainly in the majority of 
cases, this will not be discovered? As to the application of milder 
remedies, such as Lugol's solution, or some of the milder caustics, 
such as acetic or chromic acid, I see no objection, although I think 
the potential cautery should be recognized, in this connection, as a 
device capable of doing mischief. 



CHAPTER XLIV. 

MYXOFIBROMA OF THE NASO-PHARYNX. 

This is a term which is used to designate a form of neoplasm com- 
posed of fibrous connective tissue, with a more or less copious admix- 
ture of myxomatous structure, and which has a clinical history 
entirely distinct from that of pure fibroma ; and, furthermore, springs 
from the upper portion of one of the oval openings of the posterior 
nares, where the mucous membrane lining the nasal cavity proper is 
merged into the structures which we find in the vault of the pharynx. 
True fibroma, fortunately, is a much rarer occurrence than the myxo- 
fibroma. The frequency of these growths is scarcely to be judged by 
the literature of the subject, for many cases are met with in every- 
day practice which present no symptoms or complications which 
would render them of sufficient importance for publication. Yet the 
number of cases recorded is by no means small. 

It is difficult to assign any direct cause for these tumors. Sex 
seems to have a certain influence, two-thirds of the cases reported 
having occurred in females. 

It is usually met with between the ages of fifteen and thirty, al- 
though apparently no age is exempt from the affection. Panas' case 
occurred in a man aged sixty -eight. 

Symptomatology. — In the early stages of the development of the 
growth, the symptoms to which it gives rise consist merely of a cer- 
tain degree of interference with nasal respiration on the side from 
which the tumor springs, with some hypersecretion. As the neo- 
plasm increases in size, the nasal stenosis becomes more marked and 
the voice is affected. Owing to the presence of a large amount of 
myxomatous tissue in the tumor, it is soft, and develops compara- 
tively rapidly. Hence it very soon impinges upon the soft palate, 
interfering with its movements in phonation and giving rise to a nota- 
ble impairment, not only of the quality of the voice but also of clear- 
ness of articulation. Deglutition is not notably interfered with; the 
tumor, being freely movable in the pharyngeal cavity, is lifted by the 
movements of the palate during this act. 

These growths may attain considerable size without giving rise to 



324 DISEASES OF THE NASO-PHARYNX. 

any very marked symptoms of discomfort other than the interference 
with nasal respiration. After it has found a somewhat firm resting- 
place on the upper surface of the palate, and the pedicle is thereby 
relieved from the tension of the pendulous mass, the growth seems to 
assume a lateral direction, and also in part to become arrested, in that 
its increase in size goes on with much less rapidity and even shows 
a tendency to stop at this point. The tumor occasionally protrudes 
itself between the borders of the soft palate and the posterior wall of 
the pharynx, but usually it is thrown back again into the upper phar- 
ynx by the ordinary movements of the palate, and rarely shows a dis- 
position to permanently intrude itself into the lower pharynx, al- 
though a case reported by Coyne seems to have been of this nature, 
in that the lower border of the tumor rested almost on the root of the 
tongue. Epistaxis is never symptomatic of the nbro-polyp ; the ordi- 
nary faucial and bronchial symptoms, however, which occur in con- 
nection with mucous polypi may be present. In one of the cases 
which came under my own observation spasmodic asthma was entirely 
and immediately relieved by the successful removal of the tumor. 

Pathology. — The essential basis structure of the tumor is com- 
posed of bundles of white fibrous connective tissue, while scattered 
between the bundles and between the individual fibres is found a large 
quantity of myxomatous tissue. In addition to this, there are num- 
bers of fibres of yellow elastic tissue scattered throughout the growth. 
In the outer portions of the tumor, and also scattered between the 
fibres, are found large numbers of round and spindle cells. The vas- 
cular supply is fairly rich in the central and peripheral portions of 
the tumor, while in the intermediate portions of the growth it seems 
to be to a certain extent deficient. The pedicle is composed mainly 
of connective tissue. The tumor seems to be covered by the mucous 
membrane of the part from which it sprang. The deeper layers of the 
epithelium are rounded or even flattened as we recede from the sur- 
face. The attachment of the growth is, in the large majority of in- 
stances, to some portion of one of the oval openings of the posterior 
nares, usually its upper portion ; in one case reported, however, the 
attachment was to the septum, and in another to the inferior turbi- 
nated bone. 

The pathological character of the growth would seem to show that 
it originates as an ordinary mucous polyp, which, having fallen into 
the pharynx and finding room for a larger development, attains an 
unusual size. Nevertheless, this idea falls to the ground, it seems 
to me, absolutely, when we remember that the neoplasm develops in- 
variably from the margin of one of the posterior nares, a region from 
which, so far as I know, a pure myxoma has never been known to de- 



MYXO-FIBROMA OF THE NASO- PHARYNX. 325 

velop. We must regard, then, the tumor as developing primarily as 
a fibro-myxoma, and maintaining this character throughout its entire 
career, and simply explain this fact on the ground that it has its ori- 
gin from a tissue which is the meeting-ground of the nasal mucous 
membrane and the membrane lining the vault of the pharynx, two 
regions lined by mucous membrane differing in a marked degree in 
their histological and physiological characteristics, in one of which 
the prevailing form of growth is a myxoma and in the other of which 
the prevailing form of growth is a fibroma. Hence, a tumor spring- 
ing from a region in which the structures of these two cavities com- 
mingle necessarily partakes of the character of each. 

Diagnosis. — The neoplasm has a grayish-red aspect, of a muddy 
tinge, which is presented by no other form of growth met with in this 
portion of the upper air tract. It should not be confounded with a 
true fibroid, which is of a whitish-pink tinge that is absolutely char- 
acteristic. In addition to this, the insertion of a probe will easily 
demonstrate the mobility of the growth and render the diagnosis free 
from all obscurity. When the growth presents below the palate, and 
is brought under immediate ocular inspection, the diagnosis, of 
course, presents even less difficulty. In addition to this, it should be 
borne in mind that a fibro-mucous tumor never gives rise to hemor- 
rhage, facial deformity, displacement or erosion of bone, or any of the 
grave complications which attend the development of fibroma in the 
naso-pharynx. 

Prognosis. — As before stated, these growths develop somewhat 
rapidly at first, while subsequently their growth seems to become re- 
tarded, or even shows a tendency to arrest, although as regards an y 
tendency to a retrograde process or atrophy, as sometimes occurs in 
fibroma, this, I think, has never been observed, nor, so far as I know, 
any disposition to spontaneous separation or sloughing away. After 
removal they occasionally recur, although this tendency is by no 
means so marked as in the case of myxomata. 

Treatment. — These growths being pendulous in the pharyngeal 
cavity, and attached by a pedicle usually not larger than three-eighths 
to a half inch in diameter, their successful removal presents no very 
serious or great obstacles. If they hang below the border of the soft 
palate, perhaps the simplest method of extracting them is to seize the 
pendulous portion by a pair of stout forceps, the blades of which are 
armed with teeth of sufficient size to prevent the tumor escaping from 
its grasp, when the whole mass is separated by twisting the forceps 
m the hand, until the tumor comes away. This process, of course, is 
much better than simply tearing the growth away, in that by this 
means the separation is accomplished at its attachment, whereas sim- 



326 DISEASES OF THE NASO-PHARYNX. 

pie evulsion might result in unnecessary injury to healthy parts. It 
is not always feasible, however, to extract these growths by torsion, 
on account of their size ; hence, in order to facilitate the manipulation 
and to provide more room, it may be necessary to make an incision 
in the palate. The most rational method of operating is by the 
snare or ecraseur. The main difficulty here, however, consists in the 
adjustment of the loop. Linon made use of a rather ingenious meth- 
od of adjusting it, as follows : A Bellocq canula was passed through 
the nose into the oral cavity, when the ends of the wire were drawn 
back, leaving the loop in the mouth. A thread was then inserted 
into the pendulous portion of the tumor by means of a curved needle, 
and dropped through the loop, traction being exerted on the thread 
and subsequently on the wires emerging from the nose. The loop in 
the fauces necessarily was made to pass up over the growth and to 
adjust itself to the pedicle, whereupon the tube was slipped over the 
wires emerging from the nose and the pedicle severed by ecrasement. 
Most operators unquestionably nowadays prefer the wire-snare ecra- 
seur, constructed on the principle of Jarvis' snare. An instrument 
of this kind, armed with a steel wire, supplies a loop, which, in the 
hands of an operator of moderate manipulative skill, can be passed 
through the nasal cavity, and slipped over a growth even of consider- 
able size without the aid of Linon 's ingenious method. 

I have had but three cases of myxo-fibroma, in all of which the 
growth was extirpated by means of the snare and with comparatively 
little trouble. Of these two came under my observation before the 
introduction of cocaine, and the operation was done without anaesthe- 
sia. The importance of using local anaesthesia in these operations 
need scarcely be mentioned. I regard the steel- wire ecraseur as 
more feasible and in every way preferable to the use of the galvano- 
cautery ecraseur. The galvano-cautery loop is by no means so easj r 
of adjustment. It presents the possible advantage of cauterizing the 
base, which is of questionable importance, as fortunately these 
tumors show but little tendency to recur when thoroughly extirpated, 
and it is an open question whether even cauterization of the base 
retards this tendency in any degree. 



CHAPTER XLV. 

CHONDKOMA OF THE NASO-PHAKYNX. 

Our knowledge of this rare disease is based entirely on the records 
of two cases, the report of which is appended in sufficiently full detail 
to afford all necessary information as regards its clinical history, 
prognosis, and method of treatment. 

Case I. — Max Mliller reports having observed a case of enchondroma of 
the naso-pharynx in a young- man, aged 29, who gave the history of a tumor 
of this region which had commenced some five years previously, and which, 
at its onset giving rise merely to nasal stenosis without secretion, developed 
by a somewhat slow process, gradually filling up the naso-pharynx, and 
sending prolongations into both nares, while at the same time it extended 
down to the level of the soft palate, which was crowded forward into the 
oral cavity. 

The subjective symptoms consisted mainly of headaches, which were of a 
very severe character, coming on in paroxysms, and lasting from two to 
four days. Later he became subject to attacks of syncope, due, probably, to 
disturbance of the cerebral circulation. 

Access to the part was obtained by means of Langenbeck's operation of 
temporary resection of the superior maxilla, and the tumor successfully re- 
moved by means of the ecraseur. Examination revealed it to be an enchon- 
droma which had its origin from the basilar process. The operation was 
entirely successful, and there was no history of recurrence. 

Case II. — Heurtaux cites a case of a young girl, who for five years had 
suffered from gradually increasing nasal stenosis, first of the left side, and 
later of the right. In connection with these, there then developed exoph- 
thalmos, amaurosis, and broadening of the dorsum of the nose, giving rise 
to a certain amount of facial deformity. Examination showed the right 
nasal fossa to be closed by a deflection of the septum, the result of a tumor 
in the left nares impinging upon it. The finger introduced behind the 
palate discovered a hard, dense tumor filling the naso-pharyngeal space. In 
spite of the firumess of the growth the exploring needle penetrated it easily. 
An operation for its removal being decided upon, access to the growth was 
gained by the removal of the left half of the nose. The tumor was found 
adherent to the floor of the nasal cavity, to the septum, and to the posterior 
pharyngeal wall, and had invaded also the antrum. Microscopic examina- 
tion showed the growth to consist almost entirely of hyaline cartilage. The 
patient made a rapid recovery. 



CHAPTER XLVI. 



SAKCOMA OF THE NASO-PHAKYNX. 



Malignant disease having its origin in this region would seem to 
be of exceedingly rare occurrence. Of the two forms, sarcoma is met 
with much more frequently than carcinoma. And yet in either form, 
medical literature contains but a limited number of cases. 

Etiology. — Sarcoma is usually regarded as belonging rather to 
the earlier period of life. This is true as compared with carcinoma, 
and yet in the nineteen cases reported, there occurred : 



Between 1 and 10 years of age, .... 


2 


10 " 20 " .... 


5 


20 " 30 " .... 


3 


30 " 40 " 


2 


40 " 50 " 


7 



Sex seems to exercise a notable influence, in that fourteen of the 
cases occurred in males, while but five were in females. This excess 
is easily accounted for when we consider that sarcomatous tumors 
belong to the connective-tissue series, and bear a certain relation, 
therefore, to fibrous tumors, which, as we know, occur almost ex- 
clusively in males. 

Symptomatology. — In the early stages of the development of these 
growths, they give rise to no symptoms which differ in any notable 
degree from those caused by the existence of any form of tumor in 
this region which has attained sufficient size to impede normal nasal 
respiration. Offensive discharge manifests itself quite early in the 
history of the case, and is present in the majority of instances. 
Epistaxis also is liable to occur somewhat early, although it is not 
a prominent symptom, occurring in perhaps from one-third to one- 
half of the cases. The attacks, however, are rarely severe, or fre- 
quently repeated, and never become a grave symptom, as in cases of 
fibroma. The general health suffers somewhat early in the history 
of the case, due in no small degree to the offensive character of the 
discharge, which undoubtedly acts in a certain measure to impair di- 
gestion, and to vitiate the inspired air. As the growth develops in 
size, the additional symptoms of difficult deglutition, with recurrent 



SARCOMA OF THE NASO-PHARYNX. 329 

attacks of dyspnoea, set in. The encroachment of the tumor upon 
the orifice of the Eustachian tube leads to the early development of 
impaired hearing, or the complete loss of this function. 

Pathology. — The origin of these growths is usually from the bas- 
ilar process of the occipital bone, starting in the deeper layers of the 
mucous membrane lining the part, developing in the form of rounded, 
somewhat lobulated growths, which extend downward, forming a veil, 
as it were, over the posterior nares, and which more or less rapidly 
increase in bulk, while at the same time the attachment slowly ex- 
tends over a larger area. As they develop, they send prolongations 
into one or both nasal cavities, but the activity of the growth usually 
seems to be downward, gradually encroaching upon the lower pharynx, 
and crowding forward the soft palate. The}' are usually of soft con- 
sistency, and do not seem to possess the power of displacing the hard 
parts or causing their destruction. There have been cases, however, 
in which the bony structures were invaded. In others, the process 
extended through the sphenoidal and spheno-maxillary fissures. 
From the histological point of view, these growths differ in no essen- 
tial degree from a sarcoma of the nasal cavity. 

Diagnosis. — In appearance, these growths are irregular, rounded, 
and somewhat lobular, of a grayish-yellow muddy-looking color. 
They have the appearance to the eye of a soft, pultaceous mass, which 
is verified by palpation with the finger. Their recognition, however, 
by ocular inspection, can rarely be depended upon, and certain diag- 
nosis can only be made by a microscopical examination. 

The character of the tumor having been recognized, it becomes a 
matter of some importance to determine whether it arises in the nasal 
cavity or in the nasopharynx. As regards sarcoma of the nasal cav- 
ities, I think it may be stated as a rule, that it shows a marked hesi- 
tancy in making its way into the pharynx, and that the mere presence 
of a tumor, which is ascertained to be of a sarcomatous character, 
more or less completely filling the pharynx, is a pretty clear evidence 
that it had its origin in that region. 

Course and Prognosis. — A sarcoma, especially in early life, runs 
a somewhat rapid course, although this rapidity of growth is depen- 
dent in no small degree upon the special character of the tumor. In 
a general way we may state that a tumor composed of small round 
cells runs an exceedingly rapid course, while the spindle-cell tumor 
develops more slowly, and in those cases in which there is a large 
admixture of fibrous tissue the development of the neoplasm is very 
greatly retarded. On general grounds we must regard the prognosis 
in these cases as exceedingly unfavorable. 

Treatment. — The failure in all cases to even relieve symptoms by 



330 DISEASES OF THE NASO-PHARYNX. 

extirpating these tumors by means of a radical operation, and the 
fact that so many die upon the table warrants us in condemning ut- 
terly this procedure. The only question really open for discussion 
in this connection is as to the comparative merits of the use of the 
cold-wire snare or the galvano-cautery. The selection of the means, 
however, must always be decided by the individual preferences of the 
operator, and the greater skill which his own experience may have 
given him in the management of any special device. My own prefer- 
ences are decidedly in favor of the cold-wire snare. In removing a 
sarcoma by this means, the operation is to be done much in the same 
manner as that already described in connection with fibromata of this 
region, with the difference, however, that hemorrhage in connection 
with sarcoma is not to be anticipated to anything like the extent with 
which an operation for fibroma is complicated. Of course, if the 
growth has attained such size as to render simple manipulations with 
snare impracticable, wider access to the growth may be obtained by 
slitting the palate, a simple operation, which would scarcely compli- 
cate the case; or, if demanded, Bruns' operation or some similar 
preliminary operation on the external nose must be done. The clini- 
cal history of sarcoma shows that recurrence is always likely, and the 
question therefore arises how it may best be prevented. Much 
stress has been laid, especially by Lincoln, on the importance of cau- 
terizing the base of the tumor after an operation. I am disposed to 
think that there is a certain danger in this, especially in the naso- 
pharynx. Caustic agents cannot be used in this region with impu- 
nity, and it has by no means been determined that the use of a caustic 
may not, instead of destroying diseased tissue, stimulate the parts to 
a renewed malignant action. The suggestion occurs that we may 
with more safety depend on watching the parts carefully from time to 
time, and controlling any tendency to recurrence by the removal of 
the small masses as they develop, by means of the snare, especially 
as sarcoma rarely affects the lymphatic glands. 



CHAPTER XLVIL 
CARCINOMA OF THE NASO-PHARYNX. 

The literature of carcinoma of the naso-pharynx is completed, so 
far as I have been able to learn, in the report of six cases. 

In its primary development and subjective symptoms, carcinoma 
of the naso-pharynx differs in no notable degree from that of sarco- 
ma, causing obstruction to nasal respiration, together with a certain 
amount of unpleasant discharge, mixed with blood, and the deformity 
and impairment of function of the fauces according to the size of the 
tumor. Secondary enlargement of the tissues of the neck occurs com- 
paratively early in the history of the disease, and, furthermore, this 
infiltration proceeds without much change, and with little tendency 
to rapid development, for a considerable period of time. 

The diagnosis, of course, would be in most instances rendered 
fairly complete by the existence of this one symptom, although its 
thorough determination must always depend upon a microscopic ex- 
amination. 

As regards both prognosis and treatment, there is little to be said. 
The disease is inevitably fatal and runs its course in from one to 
three years. 

The plan of treatment is necessarily one which must be decided by 
the surgeon in each individual case, or even the question as to whether 
any treatment at all should be resorted to. In a case under my care, 
the successful removal of the growth by means of the snare was ac- 
complished with but a trivial amount of pain or even discomfort to 
the patient, and the relief to symptoms was not only very great for a 
time, but, furthermore, the patient was made happy for weeks and 
even months with the idea that her disease was being brought under 
subjection. 

As regards the advisability of a radical operation, such as a resec- 
tion of the superior maxilla, and procedures of this kind, there would 
seem to be very little justification for subjecting a patient to this great 
hazard, from our clinical experience of the disease as at present re- 
corded. 



SECTION III. 

EXTERNAL SURGERY OF THE NOSE. 



EXTERNAL SURGERY OF THE NOSE. 



CHAPTER XLVIIL 

EXTERNAL SURGERY OF THE NOSE. 

Under this heading is embraced a description of those operations 
by which a larger access to the nasal passages is obtained for the re- 
moval of tumors, either of the nasal cavity itself or of the naso-phar- 
ynx, and which involve : 

(1st) Incisions through the hard or soft palate, or both ; 

(2d) Incisions through the external integument alone ; and 

(3d) Incisions through the external integument, together with 
section of bone. 

Under the first group are included the following operations : 

Manne's Operation. 

This simple operation was first performed by Marine, in order to 
gain wider access to the naso-pharynx, for the removal of a fibro- 
myxomatous growth, the size of an egg, which completely filled that 
cavity, the incision being made through the soft palate, from below 
upward, by means of a bistoury, in the median line, extending from 
the tip of the uvula to the junction of the hard palate. Subsequently, 
Levret, in a somewhat similar case, slit the palate at the side of the 
uvula, thus accomplishing an equally good purpose, with a shorter 
line of incision, a proceeding regarded by Jobert as preferable. 
The operation involves no complications. The parts are subse- 
quently restored by the insertion of one or more sutures, although 
the tissues would become reunited probably in the majority of cases 
even without such interference. 



336 



EXTERNAL SURGERY OF THE NOSE. 



Maissonneuve ' S Opeeation. 

This device consists of making an incision in the median line from 
the junction of the hard palate down into the body of the uvula as far 
as may be necessary, thus securing a somewhat wide opening through 
the soft palate, while at the same time its free border is preserved. 

This procedure was originally done by Maisonneuve for the re- 
moval of a flbro-vascular tumor, which was succesfully extracted by 
means of a snare, after which the parts were reunited by a single su- 
ture. 

Nelaton 's Operation. 

Following out the method of Manne, the distinguished French 
surgeon Nelaton devised an operation for the extirpation of growths 

arising from the basilar apophysis, 
which he performed as follows : 

The uvula being seized with a pair 
of forceps, it, together with the cur- 
tain of the palate, was divided ex- 
actly in the median line as far as the 
hard palate ; then, with a stout double- 
bladed knife, this median incision 
was continued along the hard palate 
to a point about seven-eighths of an 
inch from the incisor teeth. From 
the extremity of this incision the 
membrane covering the hard palate 
was incised on either side, directly 
outward; that is, in a line perpen- 
dicular to the first, over a distance 
of from three-quarters of an inch to an inch. The wound in the 
hard palate thus assumed somewhat the form of the letter T. A 
periosteum knife was now introduced, and the mucous mem- 
brane covering the hard palate was separated along the line of 
incision, as far back as the velum. The knife was now passed 
through the junction of the mucous membrane of the nasal cavity 
with that of the palate. Next, at the outer extremity of each horizon- 
tal incision, a perforation was made through the hard palate, through 
which one blade of a stout pair of scissors was inserted, and all this 
portion of the bony palate was removed, together with a portion of 
the vomer (see Fig. 61), taking care to preserve as much as possible 
of the mucous membrane covering the upper surface of the fragment, 




Fig. 61.— Lines of Bony Section in 
Operation. 



Nelaton* 



EXTERNAL SURGERY OF THE NOSE. 337 

that is, of the floor of the nose. A large opening was thus formed, 
which gave easy access to the base of the skull. Moreover, this 
wound could be kept open for any length of time, and any evidences 
of recurrence promptly treated and dissipated. After a cure had 
been effected the margins of the palatine wound could be approxi- 
mated, and in many cases a certain amount of bone was reproduced, 
and the contour of the hard palate restored. 



Botkel's Operation. 

In order to gain a wider access to the naso-pharynx, and still pre- 
serve the free border of the soft palate, Botrel combined Maison- 
neuve's incision of the soft palate with Nelaton's operation just de- 
scribed, of resecting a portion of the hard palate ; the steps of the 
operation need not be entered into, as they differ in no respect from 
those already described. 

Kichard's Operation. 

This device accomplishes much the same purpose as that of Nela- 
ton, while at the same time the integrity of the soft palate is pre- 
served. The procedure is as follows: An incision is made in the 
median line, from the posterior border of the hard palate forward to 
the alveolus, extending well down to the bone, after which the perios- 
teum is dissected up on either side, over the whole area of the bone 
which it is designed to remove, when the bony palate, to such an ex- 
tent as may be necessary, is removed by means of a chisel, and free 
access gained to either one or both nasal cavities, according as may 
be desired. After the indications for which the operation is done 
have been fulfilled, Bichard apparently leaves the mucous membrane 
and periosteum in situ, without further procedure, although Gussen- 
bauer performed a similar operation subsequently, and inserted su- 
tures for reuniting the flaps of mucous membrane and periosteum. 



Sedellot's Operation. 

Sedillot makes a linear incision in the median line through the 
soft palate, by means of a bistoury, extending the incision through 
the mucous membrane of the hard palate as far forward as the palato- 
maxillary suture, cutting down to the bone, after which, by means of 
a periosteum elevator, the oral faces of the palatal process are de- 
nuded, and subsequently, by passing up behind the border of the soft 
palate, its nasal surface is subjected to the same manipulation. After 
22 



338 



EXTERNAL SURGERY OF THE NOSE. 



this, the horizontal plate of the palatal bone is exsected (see Fig. 
62), by means of a stout scissors or forceps. By this means, fairly 
wide access is obtained to the naso-pharyngeal cavity, for such sub- 
sequent procedure as may be indicated. The edges of the wound are 

to be reunited by sutures, with the 
prospect of complete restoratioD of 
the bony parts which have been 
removed. 

Dezeanneau's Operation. 

This operation was performed by 
Dolbeau, who assigns to Dezeanneau 
the credit of having devised it. It 
was done for the removal of a fibroid 
tumor in the nasal cavity, and con- 
sists in making a complete section 
through the hard palate, including 
the soft parts covering it, commenc- 
ing at its junction with the soft pal- 
ate, in the median line, and carrying 
the incision forward to, or beyond, the palato-maxillary suture, when 
it is carried across at right angles, until it approaches the alveolar pro- 
cess, and is again turned and carried back to the junction of the hard 
and soft palate, at its alveolar ex- 
tremity (see Fig. 63). In this man- 
ner, a quadrilateral flap, as it were, 
is formed in the hard palate, which 
can be depressed in such a manner 
as to admit of free access to the nasal 
cavity above, the flap turning on the 
junction of the hard and soft palate 
as a hinge. 

Under the second group are de- 
scribed the following operations : 




Fig. 62. 



-Sedillot's Operation ; Lines of 
Bony Section. 



Dieffenbach's Opeeation. 




.—Dezeanneau's Operation 
of Section of Hard Palate. 



Lines 



This operation is designed to ob- 
tain a wider access to the anterior 
nares, for the removal of such growths in this region as do not ad- 
mit of extraction through the natural passages, and although perhaps 
previously suggested by Dupuytren, it was first performed by Dieffen- 
bach. It consists in making an incision which, commencing at the 



EXTERNAL SURGERY OF THE NOSE. 



339 



1< >wer and outer angle of the nostril, is carried along the oase of the 
nose, in the naso-labial fold (see Fig. 64), until the ala of that side 
can be easily turned upward 
and inward, thus exposing the 
whole of the anterior chamber 
and lower meatus, with a por- 
tion of the middle meatus. If 
it is necessary to expose both 
cavities, the same operation 
can be done on the opposite 
side, the opening being no- 
tably enlarged by separating 
the columna, by an incision 
through the integument at the 
labio-columnar fold. 

The proceeding is attended 
with no special danger or 
complication, the hemorrhage 
being slight. The parts re- 
unite readily, although Dief- 
fenbach advises the insertion 

..£ q-nfi-ivpa Fig. 64.— Dieffeuuacu's Operation; Line of Cutaneous 

Incision. 




^-s** 8 




Fig. 65, 



-Lariche's Operation ; Lines of Cutaneous 
Incision. 



Labiche's Operation. 

A somewhat similar device 
was that of Lariche, who in 
order to remove a tumor in- 
volving the lower portion of 
the cartilaginous septum, made 
a Y-shaped incision having its 
ends in the lower border of 
either nostril, while the apex 
was in the median line perhaps 
a quarter of an inch below 
the columna. In this manner 
the columna was separated 
from the upper lip and the 
lower border of the septum 
(see Fig. 65) . This being turn- 
ed upward, the lower portion 
of the septum, together with 
the growth, was removed with 



340 EXTERNAL SURGERY OF THE NOSE. 

scissors, and the coluinna subsequently restored to its position, and 
held in place by sutures. 



Kouge's Opeeation. 
(See Colored Plate I., Fig. I.) 

This operation was first devised by Rouge, in order to gain freer 
access to the nasal cavities in a case of syphilitic ulceration and ne- 
crosis, and is performed as follows : The patient being turned on his 
side, to facilitate the escape of blood, the upper lip is seized firmly 
by an assistant, and drawn up over the nose in such a way as to 
thoroughly expose the gingivo-labial fold, when an incision is made 
through the mucous membrane, extending from the first molar tooth 
on one side to the same point on the opposite side, after which the 
lip and face are dissected from the bones, until the lower border of 
the anterior nares is exposed, and the septum reached, which is now 
divided by means of a stout pair of scissors, in sufficient extent to 
allow of the nose being turned up over the face, in such manner as 
to more or less completely expose the bony openings of the nasal 
passages. If necessary, the cartilaginous septum may be completely 
divided, in order to faciliate the rolling backward, as it were, of the 
lower part of the face. The facility of access to the nasal cavities thus 
gained is practically limited only by the size of their bony openings 
anteriorly. For convenience of manipulation and ease of illumina- 
tion therefore, the gain is no small one, especially when we consider 
the comparative simplicity of the operation, which, according to 
Rouge, is accomplished without any dangers, and with no great risk 
of complications. The hemorrhage is comparatively slight, the reac- 
tion not notable, and, furthermore, after restoration of the parts, 
union is complete in one or two days, the patient suffering but trivial 
discomfort as the result of the operation. The field of operation 
might undoubtedly be further enlarged, without complicating the 
procedure, by temporarily resecting one or both nasal bones, and per- 
haps removing a portion of the septum. 

Palasciano's Opeeation. 

This operation is interesting only as illustrating one of the curious 
devices which occasionally originate in the minds of surgeons. It 
consists of making an incision through the integument over the lach- 
rymal sac (see Fig. 66), which is partially dissected out, when a 
puncture is made through the os unguis, and access gained to the 



EXTERNAL SURGERY OF THE NOSE. 



341 




superior meatus through the opening, when a canula carrying a liga- 
ture is inserted, which, in some manner, is arranged around the ped- 
icle of a polyp, which, being separated in this manner, is extracted 
through the natural passages. 
Four cases are reported by Pa- 
lasciano and Rampolla as hav- 
ing been operated upon in this 
manner, though with poor re- 
sults. 

Under the last group the 
following operations are em- 
braced : 

Boeckel's Operation. 

This operation is designed 
to obtain a wider access either 
to the nasal cavity or to the 
naso-pharynx, and consists of 
a temporary resection of the 
whole body of the external 
nose, in the following manner : 
An incision is made across the 
bridge of the nose, from one la- 
chrymal sac to the other, the cut being carried well down to the bone. 
A second incision is then made, commencing at one extremity of the 
primary incision, and carried along the nasal furrow, down to the 
margin of the nostril, which it opens. A third incision separates the 
columna from the upper lip (see Fig. 67) . The bones in the line of 
the first incision are now divided by means of a chain saw, w r hich is 
entered through a puncture made directly through from the one side 
to the other. The bones in the line of the second incision are then 
divided by means of a saw (see Fig. 68), after which the septum oppo- 
site the line of the primary incision, or as far back as it can conven- 
iently be done, is separated by means of stout scissors or cutting for- 
ceps. The whole body of the nose is now turned over upon the cheek 
of the opposite side by means of a stout pair of forceps, thus fractur- 
ing the nasal process of the superior maxillary bone on that side. If, 
however, there is too much resistance, this part can be weakened or 
severed on the inner side, by means of a chisel. In this manner, free ac- 
cess to the nasal passages is obtained, but if it is desired to gain a larger 
access to the naso-pharynx, the additional step may be taken of com- 
plete resection of the vomer, and the turbinated bones also if necessary. 



Fig. 66. 



-Liue of External Incision in Palasciano's 
Operation. 



342 



EXTERNAL SURGERY OF THE NOSE. 



After the removal of the growth for which the operation was done, 
the nose is placed in position, and held by sutures through the integ- 
ument in the line of the original incisions. The parts reunite read- 
ily, without deformity, the cicatrix being scarcely noticeable. The 





Fig. 67. — Line of Cutaneous Incision in Boeckel's Fig. 68.— Line of Bony Section in Boeckers 
Operation. Operation. 

procedure is a comparatively simple one, and involves no great dan- 
ger or complications, but few vessels requiring ligature. 



Ollier's Operation. 

(See Colored Plate II., Fig. I.) 

This operation was first performed upon a patient suffering from 
a naso-pharyngeal fibroma, which, completely blocking the naso- 
pharynx, rendered nasal respiration impossible, and by pressure had 
partly destroyed the vomer. An incision was made, beginning just 
above the ala of the nose, extending upward to its root, thence across 
this, and downward to a corresponding point on the opposite side of 
the nose (see Fig. 69). The incision divided all the parts down to 
the bone. A thin-bladed saw was then made to divide the nasal 
bones and the septum, in the line of the cutaneous incision (see Fig. 
70) . The nose, thus freed from its attachment, was tilted downward 
upon the face, thus giving free access to the nasal cavity, and through 



EXTERNAL SURGERY OF THE NOSE. 



343 



this to the vault of the pharynx. The tumor was removed in a num- 
ber of pieces, by means of forceps, the nasal cavities being thoroughly 
explored with the finger for any traces of the growth remaining in 
them. The nose was then replaced, and held in position by metallic 
sutures, the periosteum not being included in the sutures. The nasal 




:.-:---^' 



Fig. 69.— Line of Cutaneous Incision in Oilier' 1 : 
Operation. 




Fig. 70.— Line of Bony Section in Oilier 
Operation. 



fossae were filled with sponges, to prevent hemorrhage. Primary 
union took place through almost the entire wound, and the patient 
was discharged cured in about six weeks. 

Lawkence's Opeeation. 



This operation is designed to accomplish the same purpose as 
those of Oilier and Boeckel, differing from them only in this feature, 
that the body of the nose is tilted upward upon the forehead. It is 
done in the following manner : An incision through the integument is 
made with a scalpel, extending from the lachrymal sac of one side, 
along the nasal furrow, to the margin of the nostril, which is opened. 
A second incision is made upon the opposite side, and in the same 
line, and lastly the columna of the nose is divided at its junction 
with the upper lip (see Fig. 71). Subsequently, by means of a stout 
pair of scissors or bone forceps, the bone in the line of each lateral 



344 



EXTERNAL SURGERY OF THE NOSE. 



incision is divided, from below upward, while the septum is divided 
in the same way (see Fig. 72) . The nose is now seized with a stout 
pair of forceps, or the fingers, and turned bodily up upon the fore- 
head, thus breaking up the suture between the nasal bones and the 
internal angle of the frontal, which thus acts as a hinge, as it were, 
upon which the whole mass turns. After the removal of the tumor, 
the nose is placed in position and held by sutures, union taking place 
readily, without deformity. It should be stated, however, in regard 





Fig. 71.— Line of Cutaneous Incision in Lawrence's Fig. 72.— Line of Bony Section in Lawrence's 
Operation. Operation. 

to this operation, that while accomplishing the same purpose as those 
of Boeckel and Oilier, it involves a somewhat greater risk, in that, the 
pedicle being so small, there is a possible danger of perfect circula- 
tion not being restored to the parts after the operation, and hence 
sloughing of the flap might occur. 



Langenbeck's Operation for Kesection of the Nasal Bone. 

This was done in order to gain access to the anterior nasal pas- 
sages, by temporary resection of the bony lateral wall of the nose, 
as follows: A primary incision, by means of a bistoury, is made, 
commencing in the median line, just above the root of the nose. 
This is carried across the bridge of the nose, and down one side, 



EXTERNAL SURGERY OF THE NOSE. 



345 



and extended along the middle of the nasal bone, till it reaches 
the ala (see Fig. 73), after which the cutaneous flap is dissected up 
by means of an elevator, until the nasal bone, covered with its perios- 
teum, is laid bare in its whole extent. The ala is then separated 
from the nasal bone, and a forceps inserted through the opening, and 
the nasal bone separated from its fellow along the median line. The 
forceps is now inserted at the outer angle of the lower incision, and a 
section made directly up through the nasal process of the superior 





Fig. 



i'3. — Line of Cutaneous Incision in Langenbeck's 
Operation. 



Fig. 74. — Lines of Bony Incision in Langen- 
beck's Operation. 



maxilla, extending toward the inner canthus, until the orbit is reached 
(see Fig. 74), thus making a small opening into the antrum of High- 
more. The piece thus separated is now seized with forceps and 
turned directly up over the eye. In this manner a comparatively 
wide opening is made into the nasal cavities, and, if necessary, access 
obtained to the naso-pharynx. When the design of the operation has 
been accomplished, the parts are restored to place, and held by su- 
tures through the integument. This operation is attended with no 
special danger or complications. 

This procedure was subsequently modified by Langenbeck (see 
Colored Plate III., Fig. I.), in that instead of the single incision 
through the integument, two incisions were made, one along the an- 
terior and another aloug the posterior border of the nasal bone, com- 
ing down to the ala, at which point they were united by an antero- 




346 EXTERNAL SURGERY OF THE NOSE. 

posterior incision, separating the ala from the lower border of the 
nasal bone (see Fig. 75). The bone was then divided along the line 

of the cutaneous incision, and 
the osteo-cutaneous flap was 
turned upward, securing the 
same opening as in the first 
operation. 

Linhakt's Operation. 

This operation is designed 
to gain access to the anterior 
nares, and is performed by mak- 
ing a linear incision from the 
root of the nose to its tip, which 
is then extended into the nostril 
of one side, after which the na- 
sal bone is seized by forceps 
and turned forcibly to one side, 
after separating its attachment 

Fig. 75— Lines of Cutaneous Incision in Langen- *° 1 ^ 1S l^llOW. 
beck's Later Operation. 

Bruns' Operation. 
(See Colored Plate IV., Fig. II.) 

The first incision commences just below the outer margin of the 
nostril of the healthy side, and is carried directly across in a hori- 
zontal line, to from half to three-quarters of an inch beyond the mar- 
gin of the opposite nostril. The incision is carried fully down to the 
bone, care being exercised not to puncture the mucous membrane of 
the gingivo-labial fold. A second incision is made directly across 
the narrowest part of the bridge of the nose, the terminus being just 
above each inner canthus. A third incision joins the outer extremi- 
ties of those two, thus extending into the cheek, somewhat beyond 
the nasal furrow (see Fig. 76). A saw is now inserted at the point 
of origin of the first incision, its tip being carried into the nasal cavity. 
A section is made through the anterior nasal spine and the sep- 
tum, and the saw carried throughout the whole extent of the original 
line of incision, the section being confined entirely to the superior 
maxilla, cutting through also the septum and the anterior portion of 
the lower turbinated bone (see Fig. 77). What Bruns accomplishes 
here is an enlargement of the original bony opening of the anterior 



EXTERNAL SURGERY OF THE NOSE. 



347 



nares, sawing out a strip of bone, as it were, from a quarter to three- 
eighths of an inch wide, surrounding this opening. In order to ac- 
complish this, as we see, the free end of the saw plays in the nasal 
cavity, the instrument being tilted, as it were, in this direction, thus 
making a bevelled cut. After the primary section is made with the 
saw, the bony septum is cut by means of a stout forceps or scissors 
from below upward, and the whole nose seized with the ringers or for- 
ceps and turned bodily over on the cheek. This operation of 




Fig. 76.— Lines of Cutaneous Incision in Bruns 1 
Operation. 



Fig. 77.— Lines of Bony Section in Bruns' 
Operation. 



Bruns is very simple and yet very ingenious, as by this means he 
obtains a wide access to the nasal passages, and, if necessary, to the 
naso-pharyngeal cavity, for the removal of neoplasms or the carrying 
out of other indications. No vessels of any size are encountered dur- 
ing the steps of the procedure, and the operation may be finished 
without notable complication. After the indications have been 
fulfilled, the parts are restored to position and held in place by 
sutures through the integument. 

It might be noticed that in one of Bruns' operations the wound 
was left open for a period covering three weeks, for the purpose of 
treating the stump of the growth, at the end of which time, the 
edges being somewhat freshened, they were easily and successfully 
reunited by sutures. 



348 



EXTERNAL SURGERY OF THE NOSE. 



Fouenaux-Joedan's Opeeation. 



An operation which accomplished much the same purpose as that 
of Bruns, and in a much more simple manner, is that devised by 
Fournaux-Jordan, and which is done as follows: A sharp-pointed 
bistoury being inserted into the gingivo-labial fold, just below the 
posterior margin of the nostril, it is carried forward into the nasal 
cavity, after which the whole of the upper lip, including the margin of 
the nostril, is severed by cutting upward. The ala of the nose is now 
cut through, in a similar manner, in a line continuous with that of the 

first incision, and the cut ex- 
tended along the lateral face of 
the nose, to a point just below 
the inner angle of the eye (see 
Fig. 78). The flaps, being now 
drawn to one side and the other, 
reveal freely the bony orifice of 
the anterior nares, which can be 
enlarged by means of the ron- 
geur, or other suitable instru- 
ment, to such size as may be 
demanded for the special mani- 
pulation for which the opera- 
tion is done. 

Huguiee's Opeeation. 

This procedure is designed 
to gain access to the naso- 
pharyngeal cavity, and consists 
of a temporary resection or de- 
pression of the lower portion of the superior maxillary bone. The 
mouth being opened, a transverse slit is made through the soft palate 
on the affected side, at its junction with the hard palate, after which, 
by means of a Bellocq's sound, a strong ligature is passed through the 
inferior meatus, thence through this slit in the soft palate, and finally 
drawn out through the mouth. The two ends of the thread are then 
tied together. An incision is then made from the commissure of the 
lips on the affected side, through the whole thickness of the cheek, 
outward to the anterior border of the masseter muscle. A second in- 
cision is made from the upper border of the ala of the nose on the 
affected side, along the nasal furrow, separating the ala from the nos- 







Fig 



-Lines of Cutaneous Incision in Fournaux- 
Jordan's Operation. 



EXTERNAL SURGERY OF THE NOSE. 



349 



tril, and is prolonged in the median line, through the whole thickness 
of the upper lip, through its free border (see Fig. 79). The large 
triangular flap thus formed is then dissected up, exposing the entire 
anterior surface of the lower half of the superior maxillary bone. 
The first incisor tooth on the affected side is then drawn, and by 
means of a bone forceps, one blade of which is introduced into the 
nostril, the alveolus is cut through. A flat-bladed saw is then passed 
into the nostril, and the entire hard palate is sawed through, care be- 
ing taken not to injure the oral periosteum. The finger is inserted at 





Fig. 79.— Lines of Cutaneous Incision in Huguier 1 
Operation. 



Fig. 80.— Lines of Bony Section in Huguier's 
Operation. 



the posterior extremity of the first incision, and the tuberosity of the 
superior maxilla is felt. Directly behind this is felt the projecting 
pterygoid process of the sphenoid bone, which is cut off by means of 
bone forceps. A narrow-bladed saw is then introduced behind the 
tuberosity of the superior maxilla, and the body of this bone is sawed 
through from behind forward, the section being made into the inferior 
meatus of the nose (see Fig. 80). Traction downward is then made 
by means of the ligature previously passed through the nostril and 
through the opening in the palate, and the entire lower half of the su- 
perior maxillary bone is depressed into the mouth, hinging upon the 
undivided oral periosteum of the hard palate. Free access is thus 
gained to the pharyngeal cavity, as well as to the antrum. The cu- 
taneous incisions necessitate the application of ligatures to the facial 



350 



EXTERNAL SURGERY OF THE NOSE. 



artery at two points. Aside from this, no vessels of any considerable 
size are divided. The bony and soft parts can be replaced, and the 
displaced bone may or may not be held in position by means of me- 
tallic sutures, according to the choice of the operator. The wounds in 
the soft parts are closed by means of sutures, and union readily takes 
place. It is ordinarily necessary for the patient to wear an obturator in 
the mouth for some time to prevent displacement of the bony fragment. 
The above description is taken from Huguier's original report, 
and is that of an operation which was done for the removal of a 





Fig. 81.— Line of Cutaneous Incision in Cheever's 
Operation. 



Fig. 82. 



-Lines of Bony Section in Cheever's 
Operation. 



fibroid tumor of the naso-pharynx. In this case, however, considera- 
ble bony necrosis resulted, which marred the success of the operation, 
bony reunion not having taken place at the end of three years, and all 
the teeth of that side having become carious. This result was un- 
doubtedly due largely to the fact that the pedicle consisted simply of 
the periosteum of the oral face of the hard palate, and that this had 
been subjected to the risk of injury by sawing through the bone from 
above, with a straight saw. 



Cheever's Operation. 

This accomplishes the same purpose as that of Huguier, in 
a much simpler and certainly in a much safer manner. The external 



EXTERNAL SURGERY OF THE NOSE. 



351 



incision is confined to one simple cut, extending from just below the 
inner canthus of the eye on the affected side, to the outer angle of the 
mouth (see Fig. 81), after which the anterior face of the lower por- 
tion of the superior maxilla is exposed, by dissecting up the flaps and 
drawing them to one side. The next step consists in the extraction 
of the first incisor tooth on the affected side, after which the alveolus 
is cut through by means of a bone forceps. The finger is now passed 
behind the body of the upper jaw, and the tuberosity being located, 
a straight saw is passed behind this, and worked up along the ptery- 





Fig. 83. 



-Lines of Cutaneous Incision in Cheever's 
Double Operation. 



Fig. 84.— Lines of Bony Section in Cheever's 
Double Operation. 



go-maxillary junction, and brought forward, thus severing the body 
of the bone (see Fig. 82). The mass is now seized with the forceps 
and depressed, thus fracturing the hard palate. In this manner the 
whole mass drops into the oral cavity, thus opening a wide access to 
the naso-pharynx. 

The advantages of this procedure over that of Huguier consist in 
the fact that a more complete circulation is maintained through the 
hard and soft palate, and also through the posterior palatine vessels 
which pass through the pterygo-maxillary fissure. 



Cheever's Double Opeeation. 

(See Colored Plate II., Fig. II.) 
This consists in the depression or temporary resection of the lower 



352 



EXTERNAL SURGERY OF THE NOSE. 



halves of both superior maxillary bones at the same time, and is per- 
formed as follows : 

An incision, commencing just below the inner canthus of the eye, 
is carried downward along the nasal furrow, to the base of the nose, 
when it is carried around the margin of the nostril, which it opens, to 
the median line, and extended down through the upper lip. A simi- 
lar incision is made on the opposite side, until it meets that already 
completed (see Fig. 83). The triangular flap is dissected from the 
anterior face of each superior maxillary bone, until the lower portion 
is completely exposed. The superior niaxillse are next cut through 
from behind forward, the saw being carried so that it emerges in the 
middle meatus of the nasal cavity (see Fig. 84). The septum is now 
completely divided from before backward, by means of scissors, when 
the mass is depressed into the mouth, hinging on the pterygoid pro- 
cesses behind. 

Waterman's Operation. 



Waterman, for the purpose of removing a nasal growth, resorted 
to a procedure very similar to that of Cheever, of depressing the 
lower portion of the jaw, only that after having exposed the face of 

the bone, and having made an 
incision in the median line 
through the hard palate, and 
also a lateral bony incision 
above the alveolus, the frag- 
ment was depressed in such a 
manner as to hinge upon the 
hard palate posteriorly, in much 
the same manner as in Cheever 's 
double operation. The steps of 
the operation do not differ in 
any essential manner from those 
of Cheever 's. 

Koux's Operation. 

This rather curious operation 
consists of a temporary resec- 
tion of the superior maxilla, in 
which the external incisions are 
confined to those points at 

which the bony sections are made for severing the bone from its 

attachments. 




Fig. 85. 



-Lines of Cutaneous Incision in Roux's 
Operation. 



EXTERNAL SURGERY OF THE NOSE. 



353 



First Step. — Division of the fronto-malar attachment. 

For this purpose, a horizontal incision over this articulation, about 
half an inch in length, is made with a scalpel, and carried well down 
upon the bone. Then, by means of a chisel or chain saw, the frontal 
process of the malar bone is cut through to the spheno-maxillary fis- 



sure. 



Second Step. — A vertical incision of the same length is made over 
the zygoma, which is cut through in a similar manner. 

Third Step. — An incision is made from the inner canthus of the 
eye, along the nasal furrow, around the base of the nose, stopping at 





-Lines of Bony Section in Roux's 
Operation. 



Fig. 87.— Line of Bony Section of the Palate 
id Roux's Operation. 



the columna; or, the incision may be extended through the median 
line, completely dividing the upper lip (see Fig. 85), after which, 
by means of a chain saw or scissors, the whole wall which separates 
the nasal cavity from the orbit is cut through (see Fig. 86), the sec- 
tion extending into the spheno-maxillary fissure. 

Fourth Step. — This consists of separating the ptery go-maxillary 
articulation, by means of a stout pair of scissors, carried up behind 
the tuberosity of the superior maxilla, this procedure being facili- 
tated, of course, by sliding back somewhat the flap of the integument, 
and operating through the oral cavity. 

Fifth Step. — The hard and soft palate are now separated on the 
same side by a transverse incision, after which the first incisor tooth 
is drawn and the hard palate, together with the alveolus, completely 
divided by means of the saw (see Fig. 87) . 

The superior maxilla is thus completely separated from all its 
bony attachments, and is simply held in place by the soft palate and 
23 



354 EXTERNAL SURGERY OF THE NOSE. 

external integument. The further procedure consists of inserting a 
pair of stout flat-bladed forceps into the line of incision through the 
hard palate, when by forcibly opening its blades the whole body of 
the upper jaw is forced laterally and upward into the temporal fossa, 
thus securing a fairly wide opening through the hard palate into the 
nasal cavity and naso-pharynx, for the removal of growths in this re- 
gion, or for such other indications as may be demanded, after which 
the parts are easily restored to position, and secured by means of su- 
tures in both the hard and soft parts. 

Boux states that a space half an inch in width is secured by this 
means, for operating in the cavities above. He further adds, how- 
ever, that this may be somewhat increased by cutting off the pter} T - 
goid process at its base, and also removing a portion of the vomer. 
If necessary, the same temporary resection may be performed simul- 
taneously on the opposite side. 

This operation would scarcely seem to afford as free an access to 
the nasal and naso-pharyngeal cavities as can be obtained by Chee- 
ver's, or even some of the simpler operations. Furthermore, although 
no large vessels are encountered during the operation, hemorrhage 
from the smaller vessels might occur, and be of such a nature as to 
render its arrest by no means an easy matter. 

Annandale's Operation. 

In order to gain access to the naso-pharynx for the removal of ne- 
oplasms, Annandale exposes the anterior nares, as in Eouge's opera- 
tion. The septum is then divided throughout its entire extent, where 
it unites with the superior maxillse. Next, the soft parts covering the 
hard palate are divided in the median line ; the soft palate may or 
may not require division, according to the extent of the growth. The 
hard palate and alveolus are then cut through in the median line, and 
the two jaws separated by prying them apart. The amount of sepa- 
ation obtainable varies from one-half to one inch. The growth is 
then removed by forceps or the snare, the parts are replaced, and held 
in position by sutures through the alveolus and palate. 



Langenbeck's Operation for the Temporary Eesection of the 
Upper Portion of the Superior Maxilla. 

(See Colored Plate IV., Fig. I.) 

This operation is really designed to obtain access to tumors in- 
vading the spheno-maxillary fossa, and yet is very properly recorded 



EXTERNAL SURGERY OF THE NOSE. 



355 



in this connection as one of the means by which access is gained to 
the naso-pharyngeal cavity. It consists of a temporary resection of 
the upper portion of the superior maxillary bone, and is performed 
in the following manner : By means of the scalpel, a curved incision 
is made through the integument, commencing at the lower border of 
the nasal bone, and carried outward with a downward curve, beneath 
the prominence of the malar bone, until it reaches the middle of the 
zygoma. A second incision, commencing just below the inner can- 




Fig. 88.— Lines of Cutaneous Incision in Langen 
beck's Operation. 




-Lines of Bony Section in Lan- 
genbeck's Operation. 



thus of the eye, is carried along, immediately below the border of the 
orbit, horizontally and outward, until it meets the first incision (see 
Fig. 88). These incisions are carried well down to the bone. At 
the point at which the incisions meet, the finger is inserted directly 
into the spheno-maxillary fossa, the spheno-palatine foramen being 
usually dilated by the growth, in many cases allowing the finger to 
pass directly into the pharynx. A straight saw is then inserted 
through this opening, its movement being guided by the finger in the 
mouth, when the body of the superior maxillary bone is cut directly 
through, first in the line of one incision, and subsequently in the line 
of the other, the section being carried completely into the nasal cav- 
ity (see Fig. 89). An elevator is now introduced behind the mass, 
which is pried out of its position and turned directly inward over the 
eye of the opposite side, thus hinging upon the nasal process of the 



356 



EXTERNAL SURGERY OF THE NOSE. 



superior maxillary bone and the external flap, which, it will be no- 
ticed, is not dissected from the bone. 

If the lower of the two primary incisions is made to commence at 
the ala of the nose, instead of the upper border of the ala, the opera- 
tion may be to an extent facilitated, in that in this case the section of 
bone can be made from within outward and from before backward, 
the saw being inserted into the nasal cavity. 

In making the primary incisions it should be borne in mind that 





Fig. 90.— Lines of Cutaneous Incision in Billroth's 
Operation. 



Fig. 91.— Lines of Bony Section in Billroth' 1 
Operation. 



the facial artery is severed by the lower cut, which, therefore, should 
be made first, and the hemorrhage properly arrested. This compli- 
cation is to an extent avoided by an incision which commences at the 
lower border of the nasal bone. Aside from this, the operation is 
not attended with any notable hemorrhage, unless it be dependent on 
the neoplasm itself, for the removal of which the operation is done. 
The fragment is easity replaced, and need only be secured by sutures 
through the soft parts. 



Billroth 's Operation for the Temporary Resection of the Supe- 
rior Maxilla. 

An incision is made with a bistoury through the integument, com- 
mencing at the root of the nose and extending in the median line to 



EXTERNAL SURGERY OF THE NOSE. 357 

its tip, when it is carried into the nostril, upon the side on which the 
operation is to be performed. A second incision is made, commenc- 
ing at this nostril and extending horizontally across the cheek, for 
about an inch and a half, to near the anterior border of the masseter 
muscle. A third incision, commencing at the root of the nose, is car- 
ried outward, just below the margin of the orbit, parallel with the 
lower incision, and to the same length (see Fig. 90). The nose is 
now severed by means of a chisel or other instrument in the line of 
the median incision, after which, by means of a straight saw, the body 
of the superior maxilla is completely divided from within outward, 
in the line of each horizontal incision (see Fig. 91). The whole 
mass is now pried out of its position by means of a leverage, acting 
in the nasal cavity, and turned outward upon the cheek, hinging upon 
the pterygoid process. The line of incisions through the bone in 
this operation is much the same as in Langenbeck's operation; 
hence, the source of hemorrhage is largely in the facial artery, which 
requires ligation. The course of the upper incision lies very near the 
infra-orbital foramen. This, however, is avoided with a little care ; 
otherwise, troublesome hemorrhage might arise from the artery, which 
emerges at this point. The restoration and securing of the fragment 
in position after the completion of the operation, is, of course, a sim- 
ple matter. 

Boeckel's Operation. 

Boeckel, in operating upon a case of naso-pharyngeal fibroma, 
adopted essentially Billroth' s method, with some minor changes, 
although reporting it as a new operation. 

It may be noted that, instead of carrying his saw completely out- 
ward in the upper section of the bone, he stops at the infra-orbital 
foramen, and then, in order to avoid the danger of wounding the ar- 
tery, inserts the needle of the chain saw through the spheno-maxil- 
lary fissure, carrying it subcutaneously until it passes through the 
spheno-maxillary fissure and emerges at his lower incision, when he 
divides the union between the malar and superior maxillary bones 
subcutaneously, after which the remaining portion of the floor of the 
orbit is divided by scissors. 

Demarquay's Operation. 

This distinguished surgeon performed the operation which bears 
his name for the first time upon a patient aged forty-nine, a female, 
suffering from a naso-pharyngeal tumor which had invaded the an- 
trum and the left nasal fossa. The operator was deterred from mak- 



358 



EXTERNAL SURGERY OF THE NOSE. 



ing an incision on the dorsum of the nose on account of the age and 
the poor condition of the patient. An incision was made from the 
internal angle of the left eye, following the nasal furrow, to the free 
margin of the nostril. From this point a horizontal incision was car- 
ried outward to the anterior border of the masseter muscle (see Fig. 
92) . Two flaps were thus formed, a nasal and a malar. 

These two being dissected up, together with the underlying peri- 
osteum, Liston's forceps were applied, and the portion of the nasal 





Fig. 92.— Lines of Cutaneous Incision in Demarquay's 
Operation. 



Fig. 93. 



-Lines of Bony Section in Demar- 
quay's Operation. 



process of the superior maxilla and the entire anterior wall of the an- 
trum were removed, enough of the nasal process being left to retain 
the shape of the nose (see Fig. 93). The tumor was then extirpated 
by means of forceps, and the margins of the wound brought together 
with metallic sutures. The patient was cured with scarcely any dis- 
figurement, and the anterior wall of the antrum was reproduced. 



M AISONNEU VE ' S OPERATION . 
(See Colored Plate L, Fig. II.) 

The operation of Maisonneuve, first proposed in 1860, has never 
been specially improved upon. This operation is done without mak- 
ing any external incisions whatever through the integument, although, 



EXTERNAL SURGERY OF THE XOSE. 



359 



if necessary, the upper lip may be divided from the margin of the 
nostril to the free border on the affected side. The lip being drawn 
well up over the nose, the anterior surface of the lower p'ortion of the 
bone is exposed by sweeping the scalpel along the gingivo-labial fold, 
until the bony opening of the anterior nares is exposed. The soft 
palate is separated by a transverse incision from the hard palate, 
and then, a first incisor tooth having been drawn, the whole of the 
hard palate, together with the alveolar process, is divided by means 
of bone forceps introduced through the nostril (see Fig. 94). Then, 
with the one blade of the cutting forceps introduced into the nostril 
and the other applied externally along the anterior face of the bone, 
the whole mass is severed, the section being carried back as far as 




Fig. 1)4. — Line of Bony Section in Maison 
neuve's Operation. 




Fig. 9.5. — Lines of Bony Section in Maison- 
neuve*s Operation. 



the tuberosity, at its junction with the pterygoid process (see Fig. 
f .)5). The fragment is now seized by forceps and wrenched from its 
position. This procedure is attended with no notable hemorrhage, 
aside from that which is dependent upon the character of the tumor 
or other complications. It gives ample access to the nasal and naso- 
pharyngeal cavities for the removal of such tumors as may exist 
there, and a large freedom of movement for subsequent manipula- 
tions. At the expiration of a few weeks, an artificial palate is worn 
with comfort, and subsequently a set of false teeth adapted to that 
side. The deformity resulting from this operation is very slight 
ordinarily, and the only objection that lies against it is the loss 
of the teeth on that side, a defect easily remedied. The very great 
advantage of the operation over temporary resection lies in the 
fact that permanent access is gained to the nasal or naso-pharyngeal 
cavit}', for the treatment of the stump, for the observation of any ten- 



360 



EXTERNAL SURGERY OF THE NOSE. 



dencies to recurrence, and for the prompt application of such remedies 
as may be indicated. Hence, when we remember that this operation is 
done in the large majority of instances for fibromas of the naso-phar- 
ynx, and that these are met with in young children, in whom there is a 
marked tendency to recurrence, it would seem in every way that indi- 
cations are best carried out, when a radical operation becomes neces- 
sary, by the performance of a permanent rather than a temporary re- 
section. As regards sarcoma, of which recurrence is to be expected 
almost with certainty, the successful eradication of the growth cer- 
tainly can be far better hoped for by the permanent removal of a por- 
tion of the jaw, for after removal of a growth of this kind the 
most constant and observant watchfulness is required, if we expect 
successfully to control its subsequent development. 



Peans Operation. 

(See Plate III., Fig. II.) 

This consists of a permanent resection of the posterior portion of 
the lower half of the superior maxilla, and is performed as follows : 

A linear incision, com- 
mencing at the root of the 
nose, is made in the median 
line, by means of a bistoury, 
and carried down to the tip of 
the organ, and into the nos- 
tril, and subsequently extend- 
ed from the lower border of 
the nostril, through the me- 
dian line of the upper lip, 
which is completely divided 
(see Fig. 96) . The flap is now 
dissected up, until the bony 
opening of the anterior nares 
and the anterior surface of 
the superior maxilla is com- 
pletely exposed. The next 
step consists in separating the 
periosteum from that portion 
of the hard palate which the 
operator designs to remove. 
The second bicuspid tooth is now drawn, and with a stout pair of cut- 
ting forceps the alveolus at this point is cut through into the cavity of 
the antrum, when the forceps are still further inserted, one blade in 




Fig. 96. — Line of Cutaneous lncisii 
Operation. 



in Peair 



EXTERNAL SURGERY OF THE NOSE. 



361 



the antrum and the other in the oral cavity. The section is extended 
back until it reaches the median line at the posterior border of the hard 
palate (see Fig. 97) . The external wall of the antrum is now divided 
in a line extending up to a point immediately below the infra-orbital 
foramen, when from this point, by means of forceps, a section is made 
extending backward in a horizontal direction to the ptery go-maxil- 
lary junction (see Fig. 98), after which the mass is seized with a 
strong forceps and wrenched from its position. In this manner 
access is gained to the posterior portion of the nasal cavity, and the 
naso-pharynx. The operation is comparatively simple and involves 




af ; - v!.v 







Fig. 97.— Line of Bony Section in Pean's 
Operation. 




Fig. 98.— Lines of Bony Section in Pean's 
Operation. 



no serious complications, and, while affording a somewhat restricted 
opening, possesses the advantage of leaving in position the incisor 
teeth, the patient being deprived simply of the last three molars and 
one bicuspid. 

Berard's Operation. 

This operation is devised to obtain access to the cavities of the 
nose and naso-pharynx, by means of a permanent resection of the 
central portion of the superior maxilla, without disturbing the alve- 
olar process, and is made as follows : 

The anterior face of the bone is exposed by making an incision 
through the integument either along the median line of the nose, or 
the side of the nose, extending down through the upper lip (see Fig. 
99). After the bony orifice of the anterior nares, together with the 
anterior wall of the superior maxilla, is exposed, a section is made of 
the nasal process, by means of a cutting forceps, one blade of which 



362 



EXTERNAL SURGERY OF THE NOSE. 



is introduced into the anterior nares and the other into the orbit, 
the direction of the incision being obliquely outward. A second 
incision is made in a similar mamier through the malar bone, at its 
junction with the superior maxillary bone, after which a section is 
made from the lower border of the bony orifice of the anterior nares, 
through the body of the bone, to the ptery go-maxillary junction (see 
Fig. 100). The detached fragment is then wrenched from position, 
thus removing the outer wall of the nasal cavity together with the 





Fig. 99. — Line of Cutaneous Incision in BerarcTs 
Operation. 



Fig. 100.— Lines of Bony Section in BerarcTs 
Operation. 



anterior wall of the antrum, giving access to the nose through an 
opening which really is commensurate with the size of the antral 
cavity. 

Huguier's Operation. 

This operation differs in no marked degree from that of Berard 
except that he removes a smaller fragment. The outer bony section, 
instead of being extended through the malar bone, is made through 
the body of the superior maxilla, almost entirely within the malo- 
maxillary junction (see Fig. 101). 



Yallet's Operation. 

This procedure consists of a permanent resection of a still smaller 
portion of the body of the superior maxillary bone, and is done as 



EXTERNAL SURGERY OF THE NOSE. 



363 



follows : An incision, commencing jnst below the internal angle of 
the eye, is carried along the nasal furrow, and around the root of the 
nose, to the nostril, and then extended from the inner border of the 
nostril down the median line, completely dividing the upper lip. 
The flap being dissected off, the bony opening of the anterior nares of 
that side is exposed, together with the anterior wall of the superior 
maxillary bone. A section of bone is now made with a chisel com- 
mencing at the lower border of the bony opening of the nares, and 










Fig. 101.— Lines of Bony Section in Huguier' 
Operation. 



Fig. 102. —Lines of Bony Section in Vallet's 
Operation. 



extending outward and parallel with the alveolus as far as the first 
bicuspid. A similar section is made, commencing in the nares and 
parallel with this, extending outward just below the infra-orbital fo- 
ramen. The outer ends of these two incisions are united by a third 
section (see Fig. 102), when, by means of stout scissors or forceps, 
the outer wall of the nasal cavity is cut, first below and then above, 
in the lines of the original parallel sections through the anterior wall 
of the superior maxilla. The fragment is not wrenched from its 
position. As will be seen, Yallet in this operation simply removes 
the anterior and inner wall of the maxillary sinus, which is thus 
opened into the nasal cavity, giving a free access to this passage, 
although a somewhat limited one to the pharyngeal vault. 



SECTION IV. 

DISEASES OF THE FAUCES. 



DISEASES OF THE FAUCES. 



CHAPTER XLIX. 

THE ANATOMY OF THE FAUCES. 

The term fauces is perhaps a somewhat unfortunate one, and yet 
we use it here in lieu of any better, as embracing that region in the 
back of the throat and oral cavity which contains the lower pharynx, 
or, as it should be termed, the oro-pharynx, the soft palate, the 
uvula, the tonsils, and the glosso-epiglottic fossa?. These various 
structures are so intimately associated in the performance of their 
various physiological functions that they really constitute an inde- 
pendent and separate portion of the air and food tract. We shall 
therefore reach a far more intelligent comprehension of these func- 
tions by grouping the parts together and designating the region which 
they constitute as the fauces. 

This region we may describe as lying immediately behind the 
oral cavity, and constituting a somewhat quadrilateral-shaped space, 
which is bounded posteriorly by the oro-pharynx and anteriorly by 
the cavity of the mouth, while its roof is formed in front by the soft 
palate and uvula and behind by an imaginary plane which extends 
from the free border of the soft palate to the post-pharyngeal wall, 
thus dividing the oro-pharynx from the naso-pharynx. Its floor may 
be described as extending from the orifice of the oesophagus to the 
root of the tongue, including in this region the arytenoid cartilages 
and commissure, the orifice of the larynx, the crest of the epiglottis, 
and the lingual or hyoid fossa?. 

The parts which call for special description are : 

The Oko-Phaeynx. — The oro-pharynx is usually described as con- 
stituting a region or space in the upper air and food tract. 

For all proper clinical consideration it is quite sufficient, I think, 
simply to describe what is usually regarded as its posterior wall. 
This constitutes a quadrilateral area, extending from the prominence 



368 DISEASES OF THE FAUCES. 

of the axis to the orifice of the oesophagus, or, as Luschka prefers to 
describe it, from the base of the uvula to the posterior extremity of 
the great cornua of the hyoid bone. It is concave from side to side 
and slightly so from above downward. Its length in the average 
adult varies from If to 2-J inches, while its width is from If to If 
irjches. It is formed of three layers — the mucous membrane, the 
submucous fibrous layer, and the muscular structures. 

The Mucous Membrane. — The mucous membrane is of the type 
ordinarily found in the food tract, in that it is covered with squamous 
epithelium, and is thin, somewhat attenuated, dense in structure, and 
closely adherent to the parts beneath. It is the usual practice to 
describe two varieties of glands as being found in this membrane, the 
ordinary acinous glands and the ductless or lymphoid follicles. 
Until we have further evidence as to the glandular character of these 
ductless follicles, I think we are hardly justified in designating them 
as true glandular structures. 

The lymphoid follicles are scattered somewhat irregularly through- 
out the deep layers of the membrane, although they show a tendency 
to aggregate themselves on either side of the pharynx, in rows as it 
were, parallel with the posterior pillars of the fauces. They are also 
somewhat thicker in the upper portion of the pharynx, where they 
seem to form outlying portions of the large mass of lymphoid tissue 
which constitutes the pharyngeal tonsil. 

The Fibrous Layer. — The fibrous layer separates the mucous 
membrane from the muscular tissues. It forms a thick aponeurotic 
structure where it is attached to the basilar process above, but grad- 
ually becomes thinner below and is lost as it approaches the oesoph- 
agus. 

The Muscular Layer. — Immediately beneath the fibrous layer we 
come upon the constrictor muscles of the pharynx, the superior, mid- 
dle, and inferior (see Fig. 103). 

The superior constrictor muscle is quadrilateral in shape, and 
arises from the lower third of the margin of the internal pterygoid 
plate and its hamular process, from the contiguous portion of the 
palate bone, and the reflected tendon of the tensor palati, from the 
pterygo-maxillary ligament, from a portion of the alveolar process of 
the inferior maxilla, and by a few fibres from the side of the tongue. 
From these various points, the fibres curve backward, and are inserted 
into the median raphe, and also by means of a fibrinous aponeurosis, 
into the pharyngeal spine of the occipital bone. 

The middle constrictor muscle overlaps partially the superior 
constrictor at its lower part. It arises from the whole length of the 
greater cornu of the hyoid bone, from the lesser cornu, and from the 



THE ANATOMY OF THE FAUCES. 



369 



stylohyoid ligament. The fibres of this muscle diverge from their 
origin, and are inserted into the posterior median raphe of the 
pharynx. 

The inferior constrictor muscle arises from the side of the cricoid 
and thyroid cartilages, the fibres curving backward to be inserted into 
the median raphe of the pharynx. The lower fibres blend with the 
muscular tissues of the oesophagus, while the upper overlap those of 




Fig. 103.— The Muscles of the Soft Palate and Pharynx, seen from the front. 1, Hard palate; 2, 
palato-pharyngeus; 3, levatores palati; 4, internal pterygoid; 5, inferior maxilla; 6, azygos 
uvulae; 7, middle constrictor: 8, inferior constrictor; 9, thyroid cartilage ; 10, superior cornu of 
the thyroid. 

the middle constrictor. Immediately beneath the latter two of these 
muscles, and separating them from the body of the vertebra on either 
side of the median line, are found the longus colli and the rectus capi- 
tis anticus major muscles, while between the superior and middle con- 
strictors courses the slender body of the stylo-pharyngeus muscle, 
which, arising from the inner side of the styloid process, passes down- 
ward and is partially inserted into the posterior portion of the thy- 
roid cartilage and partiallv merged in the constrictor muscles. 
24 



370 DISEASES OF THE FAUCES. 

The muscular movements of the pharynx proper are thus provided 
for by the three constrictor muscles, which practically constitute one 
muscle divided into three portions. These would seem to be arranged 
in such a way as to give the most vigorous constrictor action, together 
with a firm support of the pharyngeal wall, which is still further 
secured by the muscular layers overlapping each other between each 
of their divisions. Thus, the lower border of the superior constrictor 
is overlapped by the superior border of the middle, and, in the same 
way, the upper border of the inferior muscle notably overlaps the 
lower border of the middle. 

Nerves. — The nerve supply of the pharynx is derived mainly from 
the gldsso-pharyngeal nerve and the pharyngeal plexus. These sup- 
ply the mucous membrane with general sensation and the constrictor 
muscles with motion, the lower constrictor receiving some additional 
innervation from the external laryngeal nerve. 

The Plica Salpingo-Pharyngea. — Laterally the walls of the phar- 
ynx curve forward to the fold formed by the reflection of the mucous 
membrane over the palato-pharyngeus muscle, constituting the pos- 
terior palatine pillar. In the hollow of this lateral concavity there is 
found a slightly projecting fold of the mucous membrane, which ex- 
tends from the posterior lip of the Eustachian orifice downward until 
it is lost in the parts below, thus forming in its upper portion the 
anterior border of the fossa of Eosenmuller. It is designated as the 
plica salpingo-pharyngea or salpingeal pharyngeal fold. 

Properly speaking, this fold belongs to the lateral walls of the 
naso-pharynx, although in many instances it can be observed extend- 
ing down into the oro-pharynx. It consists essentially of a fold of 
mucous membrane, although this is thrown into greater prominence 
by the rich distribution of lymphoid follicles which are found em- 
bedded in it, this latter feature giving it its clinical importance, in 
that when these follicles are in a state of chronic inflammation it con- 
stitutes one of the forms of pharyngitis lateralis. 

Arteries.— The blood supply is derived from the ascending 
pharyngeal, which, having its origin in the external carotid artery, 
passes up through the deeper tissues of the neck, and coursing along 
on the belly of the stylo-pharyngeus, sends branches both to the con- 
strictor muscles and to the mucous membrane of the pharynx. 

In addition to this, a certain amount .of arterial supply is derived 
from the terminal branches of the internal maxillary, viz., the vidian, 
the descending palatine, and the arteria pharyngea suprema; and 
from the facial, viz., the ascending palatine and tonsillar arteries; 
and also from certain terminal twigs of the thyroid arteries. 

The ascending pharyngeal artery, although a vessel of some size, 



THE ANATOMY QF THE FAUCES. 371 

is not ordinarily visible on direct inspection of the pharynx, and yet 
a number of cases have been reported in which the artery was of 
such abnormal size, either on one or both sides, as to render its pul- 
sations visible on direct inspection. 

Veins. — The veins form a dense network spread out in the fibrous 
layer, the blood being collected by venous channels which follow the 
general course of the arteries. Those on the lateral wall of the phar- 
ynx empty into the facial vein, while those from the upper part empty 
into the internal jugular or the inferior petrosal sinus. 

Lymphatics. — The lymph vessels form a network which lies par- 
tially in the submucous tissue and partially in the deeper layers. 
With these last, some of the follicles which are seen on the posterior 
wall of the pharynx are in communication. This occurs largely at 
about the level of the third cervical vertebra, where the greater num- 
ber divide into two sets, which lie on the lateral walls of the pharynx, 
at a varying distance from the median line. Here they are in com- 
munication with the small lymphatic glands which are covered by the 
rectus capitis anticus major muscle. On the right side the lymphatic 
channels empty into the right ductus lymphaticus, while on the left 
side they empty into the receptaculum chyli. 

The Soft Palate, Uvula, and Pillars of the Fauces. — At- 
tached to the posterior wall of the hard palate, and projecting back- 
ward and downward, is a soft, flexible fold, composed of aponeurosis, 
muscular tissue, and mucous membrane, which is designated as the 
velum pendulum palati or soft palate. To the centre of this, pos- 
teriorly, is attached a projecting portion to which the name uvula is 
given, while laterally it is reflected to the side of the fauces in two 
folds, the anterior and posterior palatine arches, the whole constitut- 
ing both anatomically and physiologically a single organ. The apo- 
neurosis of the soft palate consists simply of a fibrous layer, which is 
attached to the hard palate anteriorly, and is gradually lost as it 
approaches the posterior border. The mucous membrane of the 
lower or oral surface of the palate is covered with squamous epithe- 
lium, as forming part of the food tract, while that of its upper sur- 
face is endowed with columnar ciliated epithelium, in that it belongs 
essentially to the air passages. 

It is endowed with both muciparous glands and lymphoid follicles. 
The only peculiarity about the muciparous glands lies in the fact 
that they are embedded deeply within the tissues, extending even 
down to the muscular tissue, whose fibres interlace about them in 
such a way that muscular contraction has a tendency to increase the 
secretion of mucus or to press it out, as it were, upon the surface of 
the membrane. 



372 DISEASES OF THE FAUCES. 

The glands are distributed somewhat evenly throughout the mem- 
brane, with the exception that at the free border of the palate and in 
the uvula no gland structures are found. Furthermore, at the ex- 
tremity of the uvula the mucous membrane is much thicker than at 
other portions of the velum, and of a less dense structure, an anatom- 
ical condition which tends to explain the facility and frequency with 
which an cedematous swelling occurs at this point. 

The muscles which are of importance as giving movement to the 
soft palate and uvula are the azygos uvulae, tensor palati, levator pal- 
ati, palato-glossus, and palato-pharyngeus (see Fig. 103), somewhat 
in the reverse order of their importance. 

The azygos uvulae is not a single muscle, but in most cases con- 
sists of two distinct bundles of muscular fibres, which, arising from 
the posterior nasal spine of the hard palate and from the contiguous 
aponeurosis of the soft, pass downward and are inserted into the tip 
of the uvula. Riidinger has demonstrated a muscle which he calls 
the azygos uvulae inferior, which runs from the mucous membrane of 
the tip of the uvula, upward, to be inserted into the anterior surface 
of the soft palate. 

The tensor palati, or better perhaps, as indicating its origin, the 
spheno-salpingo-staphylinus muscle, arises on either side from the 
outer third of the membranous wall of the Eustachian tube, and from 
the long groove at the base of the internal plate of the pterygoid pro- 
cess. From these origins, the fibres ascend vertically on the outer 
side of the pterygoid process, and are converged into a round tendon, 
which winds around the hamular process from without inward, being 
separated from this process by a small bursa. After passing along 
the hamular process, the round tendon is spread out into a broad, 
flat aponeurosis, a portion of which is inserted into the posterior 
border of the hard palate, the other portion blending with the apo- 
neurosis of the corresponding muscle of the opposite side. 

The levator palati or petro-salpingo-staphylinus arises from the 
flat surface near the apex of the petrous portion of the temjjoral bone, 
and from the cartilaginous and membranous wall of the Eustachian 
tube. Its fibres spread out, the upper being inserted into the apo- 
neurosis of the muscle just described, and the lower into the free 
border of the palate near the base of the uvula, the fibres from each 
side interlacing with those of the other. Laterally some of the fibres 
blend with fibres of the rjalato-pharyngeus muscle. 

The palato-glossus arises from each side of the base of the tongue, 
as a thin flat bundle of muscular fibres, some of them coming from 
the stylo-glossus muscle. From these origins the fibres ascend 
vertically to the anterior surface of the soft palate, where they are 



THE ANATOMY OF THE FAUCES. 373 

inserted, blending with muscular fibres of the opposite side. This 
muscle is covered with mucous membrane, and projects into the 
fauces, forming at the end a sharp, thin fold leading in front of the 
tonsil, forming the anterior pillar of the soft palate. 

The palato-pharyngeus muscle forms with its fellow a girdle, as it 
were, of muscular fibres which arises principally from the anterior 
surface of the soft palate, immediately beneath the mucous mem- 
brane, blending with the anterior fibres of the tensor palati. A few 
fibres also arise from the posterior surface of this muscle. From this 
origin the fibres run downward and backward to the posterior and 
inner side of the thyroid cartilage. Some of the posterior fibres run 
as far back as the posterior wall of the larynx, blending with fibres of 
the salpingo-pharyngeus muscle when this muscle is present. This 
muscle as it passes down behind the tonsil forms, with the mucous 
membrane which covers it, another sharp fold which projects into 
the fauces, constituting a posterior pillar of the palate, or, as it is 
sometimes designated, the posterior pillar of the fauces. At the side 
of the soft palate, and immediately in front of the anterior palatine 
pillar, a slight sulcus is formed between the rjrojecting pillar and the 
fold of the mucous membrane which is reflected from the soft palate 
to the alveolar process of the lower jaw. Allen gives to this sulcus 
the name of the precoronoid space, on account of its relation to the 
coronoid process of the inferior maxilla. 

Arteries. —The arterial supply to the palate is derived from the 
internal maxillary artery, through the descending palatine, and from 
the external maxillary or facial, through the ascending palatine. 
This last forms an intimate anastomosis with the tonsillar artery, also 
a branch of the facial. The lingual and ascending pharyngeal arteries 
also contribute slightly to the arterial supply. 

The Veins. — The veins on the posterior surface are continuous 
with the veins of the nasal mucous membrane. On the anterior sur- 
face they are more numerous, and empty into the pterygoid plexus 
and into the pharyngeal veins. 

Lymphatics. — The lymphatics of the soft palate are very numerous 
and form an anterior and posterior network, which are continuous 
with those of the base of the tongue on the one hand and of the nasal 
mucous membrane on the other. This lymph plexus is connected 
with the larger lymphatic glands, which lie in the neighborhood of 
the bifurcation of the common carotid artery, and of the greater cornu 
of the hyoid bone. 

Motoi* Nerves. — The motor nerves are derived from the third 
branch of the fifth, which supplies the tensor palati, a branch of the 
vagus, which through the pharyngeal plexus supplies the azygos 



374 DISEASES OF THE FAUCES. 

uvulae, the levator palati, and the palato-pharyngeus. The glosso- 
pharyngeus supplies the palatoglossus muscle. The facial nerve 
also probably sends motor branches to this region. 

Sensory Nerves. — The sensitive nerves are derived principally from 
the second division of the fifth, with some branches from the vagus 
and glosso-pharyngeal nerves. 

Anomalies. — In the process of development of the palate, various 
anomalies have been met with, which, while of more interest perhaps 
from an anatomical point of view, yet possess a certain pathological 
importance. In most of these there is no evidence whatever of any 
attempt on the part of nature to repair the difficulty, and yet occa- 
sionally an effort in this direction is observed. Bifid uvula is per- 
haps the most frequent anomaly met with in the soft palate, and yet 
in a very large number of cases that have come under my own inspec- 
tion I have never yet seen a case which required operative interference 
on account of any symptoms directly dependent upon the condition. 
Treiat regards this condition as one closely associated with cleft 
palate, considering both as to an extent hereditary. 

The most common form of this anomaly is that in which a slight 
furrow is observed along the median line of the uvula, the organ ter- 
minating in two tooth-like projections. 

Cases are recorded in which the palato-glossus muscle was en- 
dowed with a separate investment of mucous membrane, in such a 
way as to produce an elongated fenestra, as it were, through the 
anterior pillar of the fauces ; the condition being observed on one or 
both sides of the fauces. The abnormal opening in the faucial pillar 
may extend only through the mucous membrane of its anterior face, 
thus forming a blind pouch whose depth is limited by the thickness 
of the pillar. 

In one case a narrow slit-like orifice was seen on the free margin 
of the posterior pillar of the fauces on the right side immediately 
behind the tonsil. The opening was not more than one-eighth of an 
inch in length, its edges being in contact. From this point, a diverti- 
culum extended to the manubrium sterni, occupying the space be- 
tween the external and internal carotid arteries. In another case, 
there seemed to be a broadening or expansion of the insertion of the 
anterior pillar of each side into the sides and dorsum of the tongue, the 
result of which was that the movement of the tongue was somewhat 
hampered, its protrusion being attended with a drawing forward of the 
palate into the mouth. A somewhat similar condition was observed 
in a child in which the tongue in its middle third was adherent to the 
alveolus of each side, the effect of the condition being to render the 
child unable to take nourishment until the adhesions were broken up. 



THE ANATOMY OF THE FAUCES. 375 

The Tonsils. — This is the name which is given to a mass of lym- 
phoid tissue found between the two pillars of the fauces, and which 
is ordinarily described as an almond-shaped organ, possessing a 
somewhat definite form and outline, while again it is referred to 
simply as a mass of glands situated in this region. Now, as a matter 
of fact, it is exceedingly difficult to describe with any degree of clefi- 
niteness a typical tonsil, in that, owing to the peculiarity of its struc- 
ture and the character of the tissue which enters into its composition, 
it undergoes certain progressive changes from birth to old age, which 
are inherent in and common to all lymphoid structures. Moreover, 
these tissues are exceedingly liable to take on diseased action in early 
life, as the result of exposure, or perhaps from some systemic dys- 
crasia, in consequence of which it is not an easy matter always to 
determine whether the mass of tissue which we call the tonsil, in any 
individual case, is the result of regular and progressive development, 
or of diseased action. 

Its antero-posterior boundaries are always limited by the two 
pillars of the fauces, while, as regards its vertical extension, an ex- 
ceeding great difference is noted in individuals. This is more par- 
ticularly referable to its lower border, for, whereas its upper border 
is limited by the convergence of the two faucial pillars in the soft 
palate, its lower boundar} r is to an extent unlimited, for we not 
unfrequently see it extending down beyond the base of the tongue, 
its normal boundary, and even sending prolongations as far as the 
lateral walls of the laryngeal cavity. 

As regards the anatomical relations of this organ, I know of no 
better description than that of Delavan, as follows : " The relations 
of the tonsil to the internal carotid artery are not so intimate as 
commonly is supposed, for between the lateral wall of the pharynx, 
the internal pterygoid, and the upper cervical vertebra there is a 
space filled with cellular tissue, the pharyngo-maxillary interspace, 
in the posterior part of which are located the large vessels and nerves, 
and which lies almost directly backward from the pharyngo-palatine 
arch. The tonsil corresponds to the anterior part of this interspace, 
so that both carotids are behind it, the internal carotid one and five- 
tenths centimetres, the external carotid two centimetres distant from 
its lateral periphery." 

Perhaps we can describe the ordinary type of tonsil, in the major- 
ity of individuals in adult life, as consisting of a small, elongated, 
almond-shaped mass of lymphoid tissue, which presents on its outer 
surface from five to ten orifices leading down into blind pouches, or 
pockets, the whole forming an organ which lies deeply embedded in 
the sulcus between the two palatine arches, and which, in the ordi- 



376 DISEASES OF THE FAUCES. 

nary inspection of the fauces when at rest, does not project beyond 
the faucial pillars, and in fact is scarcely visible on gross inspection. 
The faucial tonsil in a healthy throat constitutes an organ of but 
trivial significance, either from an anatomical, physiological, or clin- 
ical point of view, and possesses an interest to us only when it 
attains sufficient size to encroach notably upon the fauces, and to 
give rise to prominent morbid symptoms. Except very early in foe- 
tal life, or in infancy, the mass of the tonsil is made up of hypoblas- 
ts tissue. This consists of cells, some round, others elongated or 
stellate, which, as seen by the microscope, constitute simply lym- 
phatic tissue. The development of the tonsil practically consists in 
the grouping together of these lymphatic cells into masses, constitut- 
ing blind follicles or lymph nodules, these nodules being separated 
from each other by layers of connective tissue, the origin of this 
connective tissue being in the hypoblastic layer, the lymphatic cells 
of which have undergone transformation into connective-tissue cells. 
The whole mass of the tonsil, then, is made up of lymph tissue of 
this character, surrounding a somewhat varying number (from eight 
to twelve) of deep, pouch-like cavities or pockets, the crypts of the ton- 
sil, formed by the development of the original invaginations already 
described as commencing in foetal life. The whole mass is covered 
by mucous membrane, which not only covers the face of the tonsil 
presenting in the fauces, but also extends down into the crypts of the 
organ. The mucous membrane is of the ordinary type, covered with 
epithelium, which is squamous on the surface and becomes cylindri- 
cal in its deeper layers. We thus find the tonsil made up of a mass 
of lymphoid tissue in which the covering mucous membrane is ar- 
ranged in such . a way that these invaginations or crypts assume 
somewhat the form of a muciparous or secreting gland, with this 
difference, however, that the epithelium which lines the tonsillar 
crypts is not of the same character as that which we find lining ordi- 
nary muciparous glands ; hence, the secreting capacity of these crypts 
is exceedingly limited, probably pouring forth nothing more than 
sufficient mucus to keep the surface moistened and lubricated. 

Arteries. — The arterial supply is derived from the dorsalis linguae, 
the ascending palatine and tonsillar, the ascending pharyngeal and 
the descending palatine arteries. The most important of these, 
probably, is the tonsillar, which enters the base of the tonsil at about 
the junction of its middle and lower thirds. This vessel possesses 
no especial importance in the healthy tonsil. When the organ, how- 
ever, is largely hypertrophied, the artery assumes a considerable 
size, and may give rise to very troublesome hemorrhage after tonsil- 
lotomy. It should be observed, however, that it is only in adult life 



THE ANATOMY OF THE FAUCES. 377 

or soon after puberty that we find this artery sufficiently developed 
to be the source of troublesome hemorrhage, which would seem to 
indicate perhaps that the blood-vessels of an enlarged tonsil in adult 
life are not only more extensive, but more thoroughly developed. 

Veins. — The veins terminate in the tonsillar plexus on the outer 
side of the tonsil. 

Nerves. — The nerves are derived from the fifth and from the 
glosso-pharyngeal. 

Lymphatics. — The gross distribution of the lymphatics has been 
sufficiently dilated upon in the description of the lymphatics of the 
pharynx. With reference to the termination of these vessels in the 
tonsil, Schmidt believes that they open by their deep extremity into 
the reticulum of the blind follicles. Batterer, however, has shown 
that the capillary network really occupies the entire follicular mass, 
forming a system of closed canals, which open neither by stomata 
nor by their extremities. 

Anomalies. — Congenital absence of both tonsils has been reported. 
In another instance, the}' consisted of pedunculated growths attached 
to the posterior pillar of the fauces, and hanging down behind the 
base of the tongue so far that it could not be seen when the parts 
were at rest, although, when brought into view on contraction of the 
posterior pillars, it almost completely filled the faucial opening. 



CHAPTER L. 

THE PHYSIOLOGY OF THE FAUCES. 

The functions of the various anatomical parts which we have 
already described as entering into the formation of the fauces are 
co-ordinate, and are therefore necessarily grouped together for con- 
sideration, the function of the tonsils being reserved for special dis- 
cussion. They are comprehended in the two physiological processes 
of deglutition and phonation, or more properly, articulation. 

Deglutition. — After the bolus of food has been properly masti- 
cated in the oral cavity, it is forced back to the faucial opening by 
the elevation of the tongue against the roof of the mouth, by the 
action of purely voluntary muscles. As soon as it reaches the base 
of the tongue, muscles whose action is largely involuntary force it 
by somewhat vermicular progressive contractions into the stomach. 
After the bolus passes the palato-glossus muscles which form the 
anterior faucial pillars, these muscles contract in such a way as to 
prevent its return to the oral cavity. Simultaneously with this move- 
ment, the food is prevented from making its way into the naso-phar- 
ynx by the contraction of the palato-pharyngeus muscles, whose 
edges are brought almost into parallelism from above downward, 
closing the opening between the lower and upper pharynx, although 
it is probable that a slight opening is left at the apex of the arch, 
which is closed by the body of the uvula. The function of the uvula 
is probably not of great importance in this connection, for, as we 
know, when this organ is completely amputated, the individual suf- 
fers no apparent inconvenience in the act of deglutition, which may 
be in part accounted for by the fact that the azygos uvulae muscle 
extends above the edge of the soft palate, forming a ridge on its 
upper surface. 

The contraction of the muscles which comprise the faucial pillars, 
both posteriorly and anteriorly, seems to be an involuntary or reflex 
movement excited by the presence of the bolus of food. 

At the same time that the faucial pillars contract, the larynx is 
drawn up beneath the base of the tongue, by the action of that group 
of muscles which is attached to the hyoid bone, namely, the anterior 



THE PHYSIOLOGY OF THE FAUCES. 379 

belly of the digastric, the mylohyoid, the genio-hyoid, the stylo- 
hyoid, and some fibres of the genio-hyo-glossus. This movement, 
which is also purely an involuntary one, accomplishes two purposes. 
By the raising of the larynx beneath the base of the tongue, the 
epiglottis falls over the laryngeal opening, thus preventing the en- 
trance of food into the air passages. It has usually been considered 
that this was the main function of the epiglottis, but later investiga- 
tion has shown that the importance of the epiglottis in this connec- 
tion has been overestimated, in that when this cartilage has been 
entirely destroyed by disease the particles of food are still excluded 
from the larynx, in deglutition, by the contraction of the aryteno- 
epiglottidean or laryngeal constrictor muscles. With the raising of 
the larynx, the pharyngeal wall is also elevated, this movement being 
aided by the contraction of the palato-pharyngeus muscle. This 
movement brings the constrictor muscles of the pharynx into such 
position that they grasp with ease the bolus of food, which, when 
seized, is carried down with the dropping, as it were, of the pharynx, 
when the bolus is passed into the oesophagus and to the stomach. 

The Function of the Tonsils. — The tonsils have, since the early 
days of medicine, afforded field for study, which, on account of the 
frequency with which they become the seat of morbid changes, has 
always been interesting, and yet, as the result of a total ignorance as 
to their true anatomical structure, have furnished us a number of most 
curious theories as to their special function in the economy. They 
were variously described as composed of ordinary glandular struc- 
ture, as a collection of small pouches in the pharyngeal wall, and as 
follicles destined to secrete a lubricating fluid to moisten the bolus of 
food, and to facilitate its passage through the oesophagus. We now 
know that the tonsils are made up of an aggregation of lymphatic 
nodules, and that their function is probably similar to that of Peyer's 
patches in the intestinal canal. But what the function of the lym- 
phatic glands really is remains still an unsolved problem. 

Even with our more definite knowledge of the microscopic struc- 
ture of the tonsil we scarcely attain to any more specific information 
as to its principal function. Indeed, we are launched upon a still 
wider sea of speculation and thought, and yet, while probably for 
some time to come the question as to the cytogenetic function of the 
tonsil must still remain an unsolved problem, I think its absorbent 
function must be accepted, for, while this is a function of no great 
importance in the general economy as a physiological process, the 
fact of its existence is rather strikingly shown as a pathological pro- 
cess, based on purely clinical grounds. It has been supposed by 
some that the tonsil supplies a favoring surface through which the 



380 DISEASES OF THE FAUCES. 

materies morbi of scarlet fever and diphtheria makes its entrance into 
the circulation; by others that the faucial tonsils protect against 
pathogenic germs entering the mouth with the ingesta, and that the 
tonsil tissue possesses the property of converting starch into sugar. 

I have arrived at the conclusion that the tonsil is an absorbent 
and not a secreting organ ; and yet I think this statement must not 
be accepted as absolute, in that the peculiar form which the lym- 
phatic tissue assumes in its development, viz., folds or ridges, as it 
were, gives rise to the mechanical formation of deep fissures and 
pockets, the so-called crypts in the tonsil, which constitute what are 
practically large tubular glands, although their secreting power is 
exceedingly limited. That they possess any function as such is 
probably not a safe statement ; that they possess a secreting power, 
however, all must accept. 



CHAPTER LI. 

ACUTE PHAEYNGITIS. 

The term acute pharyngitis should be used to describe an acute 
inflammation of a catarrhal nature, involving the mucous membrane 
of the lower pharynx only. As a matter of clinical observation, how- 
ever, I am disposed to think that an acute inflammation confining 
itself to this region seldom if ever occurs. We do, however, meet 
with an acute inflammation involving the pharynx in connection with 
the soft palate, uvula, and the pillars of the fauces — in fact, consti- 
tuting an acute faucitis, which occurs purely as an idiopathic disease, 
and ordinarily as the result of some simple exposure. I regard an 
inflammatory process of a catarrhal nature as a somewhat rare event 
in the pharyngeal mucous membrane, notwithstanding the fact that 
most of our standard text-books on diseases of the throat seem to 
affirm the opposite opinion. I should mention, however, that these 
statements refer only to an acute idiopathic pharyngitis, and not to 
manifestations of the exanthemata, such as measles, scarlet fever, 
small-pox, typhoid and typhus fevers, as well as syphilis, which may 
be considered one of the exanthemata. 

Etiology. — The attack undoubtedly may be caused by an ordi- 
nary exposure to cold, such as sitting in a draught or wetting the 
feet, or other similar indiscretions, and yet I think the mucous mem- 
brane here obeys the same rule as that which we have already enun- 
ciated in a previous chapter in regard to the mucous membrane lining 
the nasal cavity, and that is, that, so far as the upper air passages 
are concerned, an acute inflammation, in probably the very large 
majority of cases, is merely a lighting up of a chronic inflammation. 
Hence, in most instances, an acute pharyngitis results from a cold or 
some exposure, in which the local manifestation of the cold, fixing 
itself upon parts already weakened by the morbid process, attacks 
the mucous membrane of the fauces. Now, we have already made 
clear the fact that the pharynx properly belongs to the food and not 
to the air tract. Hence a morbid process in this region does not 
occur always in connection with disease of the air passages, but 
rather with disease of the food passages. An acute pharyngitis, 



382 DISEASES OF THE FAUCES. 

therefore, is usually met with as an exacerbation of a chronic phar- 
yngitis, which is dependent upon a chronic gastritis or some other 
disturbance of the digestive tract, such as torpid liver, constipation of 
the bowels, etc. The faucial region is also the seat of an acute in- 
flammatory activity in connction with a similar process in the air 
passages above. Most frequently, perhaps, it is met with as a com- 
plication of or as the result of an acute naso-pharyngitis, although 
with almost equal frequency it occurs in the course of an acute rhi- 
nitis. In these cases, however, the faucial symptoms are not usually 
so well marked as when the disease occurs idiopathically, partly be- 
cause the acute inflammatory process above gives rise to so much 
discomfort that the pharyngeal disorder is overlooked. 

I do not agree with the view that inflammation of the fauces is 
most common in young people. As we have already found in a 
previous chapter, it is the glandular and lymphatic structures in 
young people which are most liable to be the seat of morbid action, 
while in adults it is the connective-tissue structures, among which we 
may class the mucous membrane proper as one most liable to be in- 
volved in an inflammatory process. Hence, in early life a pharyngitis 
takes on a follicular form, while in adult life a purely catarrhal phar- 
yngitis is the rule. Moreover, this affection occurs most frequently 
in connection with a disordered stomach, and chronic dyspepsia is 
essentially a disease of adult life. As regards syphilis and scrofula 
their manifestations will be considered under a different category. 

The close connection between acute pharyngitis and acute inflam- 
matory processes in the naso-pharynx or the nasal cavities proper, 
does not seem to be sufficiently recognized. When an acute pharyn- 
gitis occurs in connection with a cold in the head, it is not due to an 
extension of the disease from above, but rather to an obstruction of 
nasal respiration. If, however, it occurs in coDnection with an acute 
naso-pharyngitis, this must be regarded as the result of an extension 
of the morbid process, although undoubtedly the engorgement of 
the lymphatic tissues above interfering with the return circulation of 
the blood-vessels from the parts below, necessarily leads to an acute 
engorgement of the lower area. It has been suggested that the use 
of alcohol, tobacco, highly seasoned foods, and hot drinks may excite 
an acute pharyngitis, through their local irritant action during deglu- 
tition. The faucial mucous membrane is covered with dense pave- 
ment epithelium, and is so thoroughly inured to the impact of 
substances of various kinds in the act of deglutition that I doubt if it 
is in any degree susceptible to irritants in this process. These arti- 
cles may act on the stomach and liver, but not primarily on the 
pharynx. Hot drinks are usually taken without injury to the phar- 



ACUTE PHARYNGITIS. 383 

ynx, so far as their local action is concerned ; although at the boiling 
point they may excite what is usually termed a traumatic pharyn- 
gitis, a subject which needs no special discussion. Cohen states 
that an acute pharyngitis may result from an extension of stomatitis. 
I have never observed such a tendency, and I think it must be exceed- 
ingly limited, unless perhaps in the case of mercurial stomatitis, 
wherein we occasionally find the mucous membrane of the soft palate 
and pharynx notably softened and relaxed, although scarcely consti- 
tuting a typical acute pharyngitis. Belladonna, as is well known, 
produces a hypenemic condition of the blood-vessels of the soft 
palate and pharynx, and yet in this case the membrane has usually a 
dry and glassy appearance, while the hyperemia is largely venous in 
character, giving it a darker tint than is observable in acute inflam- 
mation. Iodide of potassium, on the other hand, produces a con- 
dition of the pharynx which cannot easily be discriminated from an 
acute idiopathic inflammatory process. 

Pathology. — The pathology of the disease is the same as that of 
an acute inflammation involving the mucous membrane of any portion 
of the upper air tract, bearing in mind, however, that in the pharynx 
the parts are lined with squamous epithelium, and are very sparsely 
endowed with gland structures ; hence the prominent changes consist 
in a notable hyperemia and consequent thickening of the membrane 
involved, causing in the first stage of the attack an arrest of all se- 
cretion, viz., the dry stage. This is followed by a moderate serous 
exosmosis, with perhaps some increase of mucous secretions, although 
this is at all times scanty. 

Symptomatology. — The attack is ushered in with a feeling of gen- 
eral malaise or mild chilly sensatious, although the disease is never 
of so grave a character as to give rise to a well-developed chill. In- 
deed, the general disturbances due to the pharyngitis itself are 
usually of a somewhat trivial, character, although if the disease com- 
plicates an acute rhinitis, or more especially an acute nasopharyn- 
gitis, we may have an attack accompanied by constitutional disturb- 
ances of a somewhat well-marked character, such as decidedly chilly 
sensations, considerable prostration, and a temperature running up 
to 101° or 102° F., or even more. Accompanying the febrile move- 
ment, there may be pain in the bones, loss of appetite, and other 
evidences of systemic depression. In connection with this the patient 
experiences a sensation of dryness and discomfort about the fauces, 
with what is usually described as a scratchy feeling in the throat. 
After twelve to twenty-four hours, the parts become moistened with 
serous or sero-mucous secretions, which are quite limited in extent, 
unless in those cases in which the nose or naso-pharynx is involved, 



384 DISEASES OF THE FAUCES. 

when the discharge becomes considerable in amount. In general, we 
may state that the subjective symptoms of an acute idiopathic pharyn- 
gitis, as such, are not prominent. Cough is rarely if ever present, 
unless the larynx is also implicated in the idiopathic process. This 
is exceedingly liable to occur on the second or third day, the mem- 
brane of the larynx becoming the seat of a localized hypersemia rather 
than of an inflammatory process, giving rise to a mild impairment of 
the voice, of which hoarseness is the prominent feature. The trachea 
may also become involved, in which case there is more or less secre- 
tion from these parts, which is expelled by the act of coughing. 
While there is usually no pain in deglutition, the pharyngeal mucous 
membrane becomes somewhat sensitive to the passage of either coarse 
particles of food or fluids above a moderate temperature. Cold, on 
the other hand, is rather grateful. 

Diagnosis. — An examination of the parts should be made with 
care, the morbid process rendering this region excedingly sensitive. 
The whole mucous membrane, including the pharynx, the pillars of 
the fauces, and the soft palate and uvula, will be found to be the seat 
of a diffuse hypersemia, which gives the membrane the characteristic 
bright reddish tinge of an active acute inflammation. This is the 
appearance seen in what we regard as an ordinary idiopathic pharyn- 
gitis, the result of a simple exposure to cold. The membrane is 
reddened and slightty swollen in appearance, athough this is more in 
the appearance than in the actual condition, because, as we know, the 
pharyngeal mucous membrane is a hard, dense structure, with a 
somewhat limited blood supply, the hypersemia being largely of a 
capillary character. In the soft palate and uvula, however, where 
we find tissues more highly vascular and of a less dense consistency, 
the swelling is more marked. Especially is this true of the uvula, 
which is apt to show considerable swelling, which takes on an oede- 
matous form. 

If the attack is purely of an idiopathic nature, and not dependent 
upon or accompanied by an inflammatory process in the naso-pharynx 
or in the nasal cavities, the secretion from the parts is exceedingly 
limited. The tonsils also are somewhat swollen, projecting from the 
bed between the pillars of the fauces, and present the same hyper- 
aemic condition as the parts above described, the extent of the swelling 
being dependent upon the amount of previously existing hypertrophy. 

If the disease is secondary to an acute rhinitis or an acute naso- 
pharyngitis the pharynx proper is the seat of inflammatory changes 
already described, and is covered with a more or less profuse secre- 
tion of semi-opaque mucus or muco-pus, which diffuses itself over the 
whole region, or may collect in the central channel. The source of 



ACUTE PHARYNGITIS. 385 

this secretion, however, is in no case to be traced to the lining mem- 
brane of the lower pharynx, bnt is always poured out by the secreting 
structures of the naso-pharynx or the nasal cavity. 

Prognosis. — A simple idiopathic case of acute pharyngitis usually 
runs its course in from five to seven days and involves no danger to 
life, or any serious impairment of the general health. 

This statement should be made, however, with a certain amount 
of reservation, especially in young children, for I think there can be 
no question that a mucous membrane in a state of acute inflammation 
furnishes a favorable nidus for the development of graver diseases, 
such as croup and diphtheria. 

(Edema of the glottis has occurred in the course of acute pharyn- 
gitis, but is probably due to some other morbid condition such as 
disease of the liver or kidneys. 

Where paralysis of the palate occurs as a sequela, it should, as a 
rule, be accepted as evidence that the inflammatory process has been 
probably of diphtheritic origin. 

Treatment.— If the affection is dependent upon a morbid process 
in the nose or naso-pharnyx, no treatment is of any avail, other than 
that directed to the mucous membrane of the air passages above. 
When, however, the disease consists of an acute inflammation only 
of the parts visible by oral inspection, much probably can be done in 
the way of applications made directly to the parts. The simplest 
method of making applications is by means of a gargle. 

Chlorate of potash is perhaps as good a remedy as any in these 
cases, from five to ten grains to the ounce, the throat being gar- 
gled five or six times a day according to the discomfort of the 
patient. 

Among other salts which may be used with good effect may be 
enumerated the following : 

Sodii boratis, 10 gr. to the oz. ; sodii bicarb., 8 gr. to the oz. ; 
aluminis, 5 gr. to the oz. ; and tannin, 5 gr. to the oz. These may be 
used singly or in combination. 

A favorite method of applying astringents to the throat is by 

means of a lozenge. It is many years now since I have prescribed 

them, as the pharynx is in intimate sympathy with the stomach, and 

whether the stomach be notably deranged in an attack of acute 

pharyngitis or not, it is, I think, in all cases somewhat more sensitive 

than normal, and the nauseating sweets of which these lozenges are 

composed are ordinarily by no means agreeable to the patient. In 

those rare cases in which I have used medication in this form, I have 

preferred always that the drug should be incorporated in liquorice, 

which, even in its puritv, is exceedingly agreeable to a patient suffer- 
25 



386 DISEASES OF THE FAUCES. 

ing from this form of sore throat. For this purpose the following 
makes an excellent preparation : 

I^ Ext. eucalypti, gr. xxx. 

Sodii biboratis, . . . gr. x. 

Pulv. piment gr. vij. 

Ext. glycyrrhizse, . 3 iiss. 

M. ft. massa in troehisci No. xxx. div. 

Cocaine, beyond any drug in the pharmacopoeia, possesses the 
power of depleting the blood-vessels. Directly applied in solution 
to the pharynx, as by the atomizer, it gives rise to rather unpleasant 
symptoms and does no permanent good. Used in minute doses in 
the form of lozenges, however, it acts very agreeably. 

If the throat is irritable with a disposition to cough, or the raw 
feeling is present of which the patients so often complain, some 
sedative may be used. Of these I think preference should always be 
given to some of the milder drugs, codeine for instance, rather than to 
opium or morphine. 

If there is much secretion, which becomes thick and is not easily 
expectorated, we may use this combination. 

]^ Aminonii muriat., gr. xxx. 

Pulv. ipecac, gr. ij. 

Pulv. capsici gr. ss. 

Ext. glycyrrhizae, 3 iiss. 

M. ft. massa in troehisci No. xxx. div. 

When the inflammation is not severe, even simpler remedies than 
any of the above may be administered in an ordinary sore throat. 
I have not infrequently prescribed the use of marsh-mallows, cream 
peppermint drops, glycerin tablets, or gum drops, horehound candy, 
pure rock candy, glycerin, lemon drops, and other simple confections 
of this sort, and I am confident that in many cases the comfort and 
welfare of the patient have been far better conserved than if 1 had 
administered a nauseating cough mixture. 

Internal medication in this disease is not prominently indicated, 
and yet in all affections which are the result of an exposure to cold 
we must recognize a constitutional element, even if this is not evi- 
denced by any marked elevation of temperature. Hence, in an ordi- 
nary catarrhal sore throat, the patient should be placed upon the use 
of from six to ten grains of quinine daily, given in divided doses, or, 
if this is not well tolerated, salicin may be given in from ten to fifteen 
grain doses three times daily. If the appetite is impaired, or there 
is any notable impairment of nutrition, these drugs may be combined 
with iron, as in the ordinary mixtures of iron, quinine, and strych- 



ACUTE PHARYNGITIS. 387 

nine. Aside from this, the indications for internal medication are 
limited to the use of some of the laxative mineral waters. 

It is rarely necessary to confine a patient to the house with a cold ; 
indeed I think, if the weather is not unfavorable, a brisk walk in 
the air is oftentimes beneficial. Nor, in taking outdoor exercise, is 
it necessary to make any elaborate and special preparation, in the 
way of extra clothing, muffling up the neck, etc. Such extra careful- 
ness, I take it, rarely protects one from taking cold, but on the con- 
trary enhances the danger of such an occurrence. 

If the uvula is swollen and cedematous, it should be freely scari- 
fied, letting out both blood aud serum. If possible, the punctures 
should be made on the lower and posterior portion of the organ, 
although this is not always feasible. In addition to these, the patient 
should be directed to use freely small pellets of ice, held in the mouth 
and allowed to rest against the swollen organ. 

There are two internal remedies which seem to have a somewhat 
specific action on the circulation of the blood in the fauces. These 
are belladonna and aconite, and when the disease is obstinate their 
effect should always be tried. Of these, perhaps, the most active is 
aconite, which may be given preferably I think in the form of the 
alkaloid, aconitia, in doses of T J- n - of a grain to an adult every two 
hours until its constitutional effect is experienced in the formication 
of the fauces, and the numbness and tingling of the extremities. In 
administering belladonna, we give the tincture with the idea that 
perhaps its local action in deglutition may add possibly to its bene- 
ficial effects, giving from three to five drops in a dessertspoonful of 
water every two hours until dryness of the fauces is produced. 

It is an important duty of course, in these cases, to ascertain 
whether any complication exist in the nasal passages or in the naso- 
pharynx, and to carry out such indications as may appear, for the 
control of these affections. 



CHAPTER LIL 

CHEONIC PHABYNGITIS. 

By this term it is intended to designate a chronic inflammation of 
the mucous membrane lining the oro-pharynx, of a purely catarrhal 
nature, in which the morbid process involves the mucosa proper, and 
not the glandular or lymphoid structures. The inflammatory process 
confines itself almost exclusively to the pharyngeal mucous membrane ; 
the soft palate, uvula, and pillars of the fauces not usually being in- 
volved in the morbid action, although, when the tonsils are mode- 
rately hypertrophied, we frequently find that they are in a state of 
chronic hyperemia and turgescence. 

Etiology. — Chronic pharyngitis is in no instance the result of 
repeated attacks of acute inflammation of this region, but on the con- 
trary the chronic process sets in first, whereupon its clinical history 
is marked by repeated attacks of acute catarrhal sore throat. More- 
over it is an excedingly rare event to meet with a chronic pharyngitis 
as an uncomplicated idiopathic affection; indeed, I am of the opinion 
that the disease is an exceedingly rare one, if we insist that its recog- 
nition shall be based on distinct evidences of morbid action in the 
mucous membrane lining the oro-pharynx. In the majority of in- 
stances it is dependent upon some form of chronic gastritis. The 
most frequent form of gastric disturbance which gives rise to a 
pharyngitis is undoubtedly that due to chronic alcoholism. 

We frequently meet with cases in which the use of tobacco gives 
rise to more or less distressing symptoms referable to the pharynx. 
In these cases I do not think that the tobacco directly excites the 
pharyngitis, but that its use aggravates the existing chronic inflam- 
mation, and the nicotine absorption produces an unpleasant gastric 
disturbance, which reacts secondarily on the pharynx. I think, then, 
we are warranted in the statement that the use of tobacco may aggra- 
vate an existing pharyngitis, but can produce it only secondarily, by 
first giving rise to a gastric catarrh. While I regard a chronic 
pharyngitis in the very large majority of instances as secondary to a 
gastric disorder, we occasionally meet with it, although perhaps 
rarely, in connection with a chronic naso-pharyngeal catarrh. In 



CHRONIC PHARYNGITIS. 389 

tliis case it is due probably to the extension of the inflammatory pro- 
cess from the upper pharynx to the tissues below. This is aggra- 
vated to a certain extent by the fact that the naso-pharyngeal disorder 
is characterized by a profuse secretion of muco-pus, which is of a 
thick and tenacious character, and is expelled with considerable diffi- 
culty. While, therefore, a chronic pharyngitis may occasionally 
accompany a chronic naso-pharyngeal catarrh, it should be stated 
that this is rare, the morbid process in the naso-pharynx usually 
confining itself to this region, and, when diseased action in the pas- 
sages below is caused by it, the morbid process usually passes over 
the oro-pharynx, to set up inflammatory changes in the larynx and 
the tissues beyond. 

Another cause of the disease under consideration unquestionably 
may be found in some obstructive lesion of the nasal cavity proper. 
The most frequent of these, undoubtedly, is an hypertrophic rhinitis. 
This form of pharyngitis is usually of a somewhat mild character, 
and gives rise to no very notable symptoms referable to the faucial 
region. 

Pathology. — The starting-point of this affection probably consists 
mainly of a general hyperemia of the blood-vessels coursing through 
the membrane, followed by a moderate degree of hypernutrition, 
together with a slight excess of the normal amount of secretion. The 
hypernutrition, however, leads to no marked hypertrophy of the 
tissue, the morbid process expending itself largely in the engorge- 
ment of the blood-vessels, which becomes chronic. The membrane 
is thickened as the result of this hyperemia, and also somewhat from 
a structural thickening of the mucosa proper, by the deposit of con- 
nective-tissue cells in the deeper layers. The blind follicles or lymph 
structures are not involved. The muciparous glands are but few in 
number, in the normal state, and these undergo no notable changes. 

Symptomatology. — The symptoms to which a chronic pharyngitis 
gives rise are those due in the main to the disease on which the affec- 
tion depends. If it occurs in connection with chronic gastritis, the 
pharynx is -the seat of a constant sense of discomfort, with a feeling 
which the patient describes as one of rawness. There is no marked 
pain in swallowing, and yet highly seasoned foods or hot drinks pass 
the fauces with a certain amount of discomfort. If there is any 
marked excess of secretion, it is due to an accompanying naso- 
pharyngeal disorder, although there is a certain amount of secretion 
from the pharynx itself. The region is excessively irritable and intol- 
erant of examination, this irritabilit3 r being closely connected with 
the irritable stomach which is the frequent cause of the affection. 

Diagnosis. — If the disease is dependent upon gastric disturbance, 



390 DISEASES OF THE FAUCES. 

the membrane lining the lower pharynx will be found to be in a state 
of chronic inflammation, characterized by marked venous congestion, 
the inflammatory process usually being limited by the posterior pil- 
lars of the fauces, and rarely extending in any degree to the soft 
palate or uvula, although in aggravated cases these regions are in- 
volved in the morbid process. The color of the pharynx in these 
cases is characteristic, presenting a deep red, highly congested, beefy, 
raw-looking membrane, which resembles a chronic catarrhal inflam- 
mation of no other region. The surface is soft and velvety, and yet 
it presents an angry look. 

If the disease is dependent upon disease of the naso-pharynx, we 
find the same congested appearance of the membrane, although in a 
much less degree than that above described, while the soft palate and 
uvula are more liable to be involved in the morbid action, the mem- 
brane being swollen, congested, and notably relaxed. In this con- 
dition the mucous membrane is also freely coated with mucus, the 
source of which is in the glandular tissue of the naso-pharynx. 

When the disease is dependent upon an hypertrophic rhinitis, the 
membrane assumes a somewhat dryer and glazed aspect, while at 
the same time it presents evidence of chronic inflammation, in the 
notable condition of hyperemia, together with slight tumefaction. 

The recognition of a pharyngitis dependent upon gastric disturb- 
ance is of importance mainly from a symptomatic point of view. 

Treatment. —Although chronic catarrhal pharyngitis is usually 
a secondary affection, local treatment is of a certain amount of im- 
portance, although no topical applications can be of any avail until 
the active cause of the affection has been removed. If the disease is 
dependent upon a naso-pharyngeal catarrh or an obstructive lesion 
in the nose, the main indications for treatment are such as are directed 
to the cavities above. If the disease is dependent upon the use of 
tobacco and consequent gastric symptoms it must be interdicted. 

It is not the province of this work to lay down any course of 
treatment for gastric catarrh. Accepting the pharyngitis as evidenc- 
ing the existence of this, a course of treatment is imperative. The 
general rules which should govern this are familiar to all. 

It is hardly necessary to state that the use of alcohol must be ab- 
solutely interdicted. Local applications should be made, at intervals 
of two or three days to the pharynx, of one of the following : 

Argenti nitrat., gr. 10 to 20 to the oz. 

Zinci sulphatis gr. 10 to 20 to the oz. 

Liq. ferrri persulphatis, tt^ 10 to the oz. 



CHAPTER LIIL 

CHKONIC FOLLICULAK PHAKYNGITIS. 

This disease belongs essentially to the pharyngeal mucous mem- 
brane proper, without in any notable degree involving the tissues of 
the soft palate or uvula. It consists of a chronic inflammation of the 
lining membrane of the pharynx, in which the activity of the morbid 
process expends itself in the follicles, giving rise, mainly, to certain 
hypertrophic changes. This, in itself, would not excite aoy notable 
symptoms, were it not for the fact, which is confirmed by repeated 
clinical observation, that this follicular hypertrophy seems, in some 
rather obscure way, to involve the peripheral nerves, as the result of 
which the pharyngeal membrane becomes not only abnormally sensi- 
tive and hyperjesthetic, but also the seat of certain painful symptoms 
of a neuralgic character. 

Etiology. — The disease undoubtedly commences in the earlier 
years of life. As we have already observed in young children, when 
the structures which compose the pharyngeal tonsil are in a state of 
hypertrophy, there will be seen scattered over the lower pharynx a 
number of small, rounded nodules, whose presence really constitutes a 
condition of chronic follicular inflammation. I am disposed to think 
that in early life these changes in the follicles in the lower pharynx 
are of such a character that they cause practically no symptoms 
whatever. When a lymph follicle has become the seat of hyper- 
trophic changes, these probably remain to a certain extent perma- 
nent, the adenoid disease of the upper pharynx undergoing a 
retrograde process, by which a naso-pharyngeal catarrh is developed 
in adult life, while the follicular disease of the lower pharynx in 
child life results in a chronic follicular pharyngitis in adult life. In 
other words, a follicular pharyngitis in a child is a disease of no 
especial clinical significance ; in adult life it may become the source 
of no little annoyance. 

Underlying the development of all these forms of hypertrophy of 
the lymphatic glands, including pharyngeal and faucial tonsils and 
pharyngeal follicles, we must recognize the presence of that curious 
condition which we call the lymphatic diathesis, which, while not 



392 DISEASES OF THE FAUCES. 

constituting scrofula, is closely allied to it. Thus, we recognize the 
same general tendency in the hypertrophy of the pharyngeal follicles, 
and also in the enlargement of the lymphatic glands of the neck, and 
yet the clinical history of the two presents a markedly different pic- 
ture. If this view be accepted, we can easily understand how the 
development of the disease is encouraged by improper nutrition, liv- 
ing in a damp, unhealthy atmosphere, and by other hygienic sur- 
roundings of a vicious character. 

A follicular pharyngitis is more frequently observed in women 
than in men, and yet, probably, it exists with equal frequency in 
either sex. The fact that we see it more frequently in women is 
easily explained on the ground that these follicles make themselves 
felt more acutely, and give rise to more notable symptoms in individ- 
uals of a somewhat delicate constitution and nervous temperament. 

I do not indorse the view that the follicular affection may develop 
from an ordinary catarrhal inflammation, as the two processes are 
practically distinct in their whole clinical history. 

Any condition which impairs the general health, or interferes in 
any way with the normal functions, is liable to give rise to a sore 
throat when enlarged follicles exist, the general conditions causing 
the local disease to manifest more or less distressing symptoms, 
which are entirely in abeyance so long as the general health is good. 

Many writers have asserted that the rheumatic and gouty dia- 
theses, as well as syphilis, predispose to follicular pharyngitis. I 
think I have made clear my view, that enlargement of the lymphatic 
follicles is due, as a rule, to the existence of what we call the lym- 
phatic temperament. And I repeat that a chronic follicular pharyn- 
gitis is a local disease of the oro-pharynx, in which the follicles have 
undergone hypertrophic changes in early life, as the result, in the 
majority of instances, of a peculiar habit, which we call the lymphatic 
diathesis ; that these hypertrophic changes have remained while the 
general dyscrasia, probably, has disappeared with the growth and 
development of later years. When these follicles make their pres- 
ence felt in the pharynx, it is purely as a local disease, and, while the 
symptoms may be aggravated by the coexistence of a morbid process 
in the nose or naso-pharynx, I do not believe that the follicular dis- 
ease occurs as the result of the morbid process in the passages above. 

Pathology. — Up to comparatively recent times, the part played 
by the lymphatic structures in the morbid process seems to have 
been entirely overlooked, and the view held that in follicular pharyn- 
gitis the morbid changes consisted in an hypertrophy of the mucipa- 
rous glands. 

That the small hypertrophied masses in follicular pharyngitis 



CHRONIC FOLLICULAR PHARYNGITIS. 393 

should have been considered as diseased muciparous glands is easily 
understood when we consider the close relation, both as to location 
and number, they bear to the normal secreting glands, though the 
essential morbid process consists of changes in the lymphatic tissues. 
The reason of this is very clearly demonstrated by Sallfield, who 
has shown us that the activity of the morbid process involves prin- 
cipally those lymphatic follicles which are grouped about the muci- 
parous glands, and consists in an increase of the normal lymph 
elements, which are found distributed not only about the extended 
portion of the follicle, but about its outlet. The greatest activity of 
the process, however, is expended in the lymph tissue which is de- 
X)Osited about the follicular duct. Now, we should naturally suppose 
that the result of this would be to produce a stenosis of the duct. 
This, however, is not a feature of the disease, which, Sallfield explains, 
is due to a deposit of lymph tissue about the duct acting in such a way 
as to draw outward upon the duct walls, rather than to press inward, 
thus creating an abnormally open-mouthed follicle. In connection with 
this lymphatic hyperplasia, there is also a certain amount of hyper- 
trophy of the elements which go to make up the normal muciparous 
gland. This is, however, of such slight extent, as compared with the 
morbid changes in the lymphatic tissue, that the disease process in this 
latter may be considered as constituting the whole of the morbid 
activity. In certain instances we may find this lymphatic hyperplasia 
extending, either locally or diffusely, in the deeper layers of the mu- 
cous membrane, thus constituting somewhat broadened plaques rising 
above the surface of the pharyngeal membrane, although, as a rule, 
the disease manifests itself in the small, rounded eminences usually 
seen on the wall of the pharynx. There is, also, a certain amount of 
hyperplasia involving the whole area of lymphatic distribution in the 
deep layers of the mucous membrane, giving rise to a thickening of 
the whole structure, although this is not apparent, usually, on gross 
inspection. I have already endeavored to make clear my under- 
standing of the significance and history of lymphatic hyperplasias, 
viz., that the primary stage of the disease commences in child life, 
the morbid process being practically the same, whether it give rise to 
adenoid growths in the pharyngeal vault or to hypertrophy of the 
follicles of the lower pharynx. When this hyperplasia first occurs, 
the lymph follicles are large rounded masses, of soft and yielding 
consistence. As years go on, they seem to undergo certain changes, 
which, while not probably constituting either true atrophy or sclero- 
sis, are characterized by a marked diminution in size, with increased 
density. In certain cases, undoubtedly, they disappear of them- 
selves, the lymph tissue being reabsorbed. In other cases they 



394 DISEASES OF THE FAUCES. 

remain, constituting permanent morbid changes ; when located in the 
vault of the pharynx, giving rise to a naso-pharyngeal catarrh; 
when located in the oro-pharynx, giving rise to a chronic follicular 
pharyngitis. 

We occasionally find the follicular disease complicated by a 
chronic catarrhal inflammation of the pharyngeal mucous membrane. 
In this case, however, the latter process bears no special relation to 
the follicular hyperplasia, nor do I think it is in any way dependent 
upon it. As before intimated, we may find the diseased follicles 
showing themselves in minute, rounded eminences, scattered over the 
middle area of the oro-pharynx, or they may aggregate themselves 
on the sides of the pharynx, and immediately behind the posterior 
pillars of the fauces, constituting more or less prominent ridges in 
this region, this form of the affection being termed pharyngitis late- 
ralis. In well-marked cases of pharyngitis lateralis, we occasionally 
find the posterior pillar of the fauces adherent to the elevated ridge 
on the pharyngeal wall. 

Symptomatology. — As before stated, the presence of enlarged folli- 
cles in the pharynx, in child-life, is an exceedingly common occur- 
rence, and yet at this period of life they seldom give rise to any 
symptoms. When, however, they persist till adult life, and have 
undergone retrograde changes, they give rise to symptoms far more 
marked than one would suppose could be caused by such an insignifi- 
cant local lesion ; but we must remember that no region of the body 
is endowed with a higher degree of both motor and sensory innerva- 
tion than the throat, and so we find that any impairment of function 
or even slight morbid change in the throat is liable to be attended by 
symptoms which, although not distressing in character, are a source 
of exceeding great annoyance, being constant and harassing. 

It is a somewhat prevalent idea that the prominent symptom of a 
disease process in the mucous membrane, in any portion of the air 
tract, is excessive secretion, and that any morbid process in the throat 
usually gives rise to what, in common parlance, is called a sore 
throat. I am disposed to say that hypersecretion is in no way a 
symptom of follicular pharyngitis. In those rare instances in which 
the muciparous glands which the hypertrophied lymphoid tissues 
inclose are preserved or enlarged, mucus undoubtedly may accumu- 
late within the crypt, and undergo cheesy degeneration. This is 
purely an adventitious occurrence, and in no way complicates the 
disease. These little masses of cheesy matter make their appearance 
in the mouth of the follicle, and are forced out usually in the act of 
deglutition. 

Notwithstanding assertions that pain is not a common symptom 



CHRONIC FOLLICULAR PHARYNGITIS. 395 

of follicular pharyngitis, I am disposed to regard this as by far the 
most constant and most prominent symptom in this affection. The 
pain is usually of a dull, neuralgic character, referable to and seem- 
ing to diffuse itself over the back of the throat, and yet, when the 
fauces are tested we often find a certain amount of tenderness in the 
enlarged follicles which is more than hyperesthesia, thus apparently 
establishing the fact that this sensitiveness is due to a localized nerve 
condition. This symptom constitutes a constant source of annoy- 
ance, and yet varies in a marked degree at different times. This is 
mainly the result of over-use of the muscles of the throat. Thus, for 
instance, while deglutition is not painful, the movement of the throat 
in deglutition seems to give rise afterward to an aggravation of the 
discomfort. In the same way, the excessive or prolonged use of the 
voice also seems to aggravate this symptom. It is by no means easy 
to explain why a follicular pharyngitis should give rise to this local- 
ized pain, unless we venture the theory that the terminal filaments of 
the sensitive nerves become involved to some extent in the hyper- 
plastic process which invades the lymphatic tissue. When the lymph 
nodules have undergone the retrograde changes by which they become 
reduced to one-third or one-fourth their original size, it seems not 
altogether improbable that the terminal filaments become subjected 
to a certain amount of pressure, which is to an extent constant. 
This pain is referable to the whole of the pharynx, but we must bear 
in mind that while the separate follicles are the seat of the most 
marked hyperplastic changes, there is a certain amount of diffuse 
lymph tissue throughout the whole of the mucosa proper. In ad- 
dition to this, there is an undoubted addition to the amount of blood 
circulating, not onl}' in the mucous membrane, but in the diseased 
follicles. Hence, this varying condition of blood pressure will ac- 
count for the neuralgic sj'mptoms to which the disease gives rise. 

Most writers mention hoarseness as indicative of follicular disease 
of the pharynx. Now hoarseness is usually an accompaniment of 
catarrhal inflammation of the larynx, whereas this affection does not, 
I think, in any case give rise to any extension of the catarrhal pro- 
cess into the air passages below. The vocal weakness, I think, is 
really to be considered an impairment of muscular action in the 
larynx, due to a reflex disturbance acting through the pharyngeal 
plexus of the sympathetic, and thence upon the motor innervation of 
the laryngeal muscles. In this way the voice, while apparently pre- 
serving its tone, seems to weaken and break down under any unusual 
or prolonged use, and especially in the nicer manipulation of tones 
of the singing voice. In the same way the muscles of the pharynx 
are slightly hampered in their action, so that deglutition, while per- 



39G DISEASES OF THE FAUCES. 

haps not especially difficult, is not accomplished with perfect ease 
and facility, the act also being accompanied with some little discom- 
fort, owing to direct pressure on the diseased tissues. This is par- 
ticularly true in that form of the disease in which the lateral masses 
of glands are involved, the so-called pharyngitis lateralis. 

Cough usually accompanies the disease. Weather and climate 
seem to have little influence except so far as they affect the general 
health. Liability to cold, or acute exacerbations, is not usually ob- 
served, nor does this affection appear to bear any close relationship 
to simple catarrhal inflammations involving the upper air passages. 
It is more frequently met with in the lower walks of life, where poor 
hygienic surroundings, improper clothing, etc., tend to develop that 
peculiar condition under which the lymph structures take on that 
morbid activity which is so closely allied to scrofula. 

Diagnosis. — I am disposed to think that there has been no little 
carelessness exercised by physicians in their examinations of those 
portions of the fauces which are seen on direct inspection; I do not 
think that this examination should ever be made without the use of 
the concave reflecting mirror. When this is used the diagnosis be- 
comes a matter of exceeding simplicity. The mucous membrane of 
the oro-pharynx has the pinkish-white tint of an ordinary healthy 
mucous membrane, while scattered about over its surface and project- 
ing from it will be observed a number of bright red masses of a 
rounded contour and shining aspect, which constitute the diseased 
follicles, standing forth in marked contrast with the normal mucous 
membrane upon which they rest. 

The tonsils are usually somewhat enlarged and the uvula is elon- 
gated ; this, I think, is more apt to be the case when the pharyngeal 
disease is complicated with naso-pharyngeal catarrh. 

Prognosis. — The disease is essentially a chronic one; it gives 
rise to no changes in the air passages beyond. It is practically a 
local disease from its outset, and remains so during its whole exist- 
ence. I am confident that the area of distribution of the disease is 
in the lymph follicles in childhood, and that no genuine extension is 
possible in adult life. Furthermore, I have never seen anything in 
the laryngeal mucous membrane which warranted me in making a 
diagnosis of true follicular disease in that region. 

What the ultimate history of these follicles is, it is not easy to 
determine. Probably the same retrograde movements which we have 
already described continues until they disappear or cease to give 
rise to any symptoms. Their history goes through the whole period 
of middle life, and extends over a period of twenty -five or thirty-five 
years. 



CHRONIC FOLLICULAR PHARYNGITIS. 397 

Treatment. — That measure which accomplishes the least destruc- 
tion to surrounding health}' tissues is the one which will commend 
itself most favorably to our consideration. For this purpose we may 
use chemical agents, the actual cautery, or the galvano-cautery. 
Of these the chemical agents, of which nitrate of silver and carbolic 
acid are usually employed, are objectionable, as their action is 
feeble and cannot well be circumscribed. 

The clinical indications are perfectly clear to destroy the fol- 
licles and they are best destroyed by the galvano-cautery. Of course 
in a pharyngitis lateralis the destruction of tissue is necessarily 
somewhat extensive, and the inflammatory reaction is more severe, 
but it is not usually a source of much trouble except in nervous 
women, in whom this procedure is liable to give rise to a considerable 
degree of constitutional disturbance. As a rule, it is perfectly feas- 
ible at a single sitting to destroy all the follicles, although it is well 
to go over the pharynx at intervals of a week, until ocular inspection 
shows them to have been competely eradicated. Of late years, I 
have used an instrument with a small point, which, when heated to a 
red heat, can easily be made to pass directly through the whole mass 
of the enlarged follicle, and indeed through the whole thickness of 
the mucous membrane. If necessary, if the follicle is large, or if it 
is a broadened plaque, a number of these punctures may be made. 
The result of this is the complete destruction of the follicle, while at 
the same time the inflammatory reaction is reduced to a minimum. 
Lennox Browne attaches a certain amount of importance to destroy- 
ing the blood-vessels which are seen coursing in the superficial tis- 
sues of the pharyngeal membrane, thus cutting off the blood supply 
from these masses. The difficulty about this, of course, is that we 
lack evidence to show that these blood-vessels, which are visible in 
the pharyngeal membrane, are the nutrient vessels of the follicles, 
and furthermore, the destruction of the tumor itself is quite as easy, 
and a much more prompt and direct method of eradicating the dis- 
ease. In addition to the mere destruction of tissue, I think in mam- 
cases certain general measures for the correction of the constitutional 
habit are indicated. These consist in the administraton of general 
tonics, such as barks and iron, strychnine, etc., together with cod- 
liver oil, hypophosphites, etc. These measures, however, will be 
carried out according to such clinical indications as appeal to the 
ready intelligence of every practitioner. It has been a standing 
practice among specialists to interdict the use of tobacco and alcohol, 
in all forms of catarrhal diseases of the upper air passages. I think 
this is scarcely called for, as there are after all patients who have 
been addicted to the use of one or both, and to make a sudden change 



398 DISEASES OF THE FAUCES. 

is unnecessary, and may even be harmful. In this disease I question 
if the use of alcohol has any effect in one way or the other, unless we 
have a complicating pharyngitis or stomach disturbance, and even in 
this case I think the influence of the habit is not marked. The use of 
tobacco, on the other hand, seems to have a notable influence on those 
affections of the upper air passages which are characterized by lym- 
phatic hyperplasias, such as tonsillitis and naso-pharyngeal catarrh, 
as well as follicular disease of the pharynx. While, then, a patient is 
under treatment, I think it wise either to interdict or curtail the use 
of tobacco until a cure is completed. After this has been accom- 
plished, of course, the habit may be resumed with impunity for, cer- 
tainly, while the use of tobacco may aggravate an existing follicular 
pharyngitis, it can in no way produce it ab initio. 



CHAPTER LIV. 
ACUTE INFECTIOUS PHLEGMON OF THE PHAEYNX. 

This is a name given by Senator to a curious and usually fatal 
disease, in which the prominent local manifestation is a phlegmonous 
inflammation commencing usually on one side of the oro-pharynx, 
and extending through the food and the air passages beyond ; it ter- 
minates in death at the end of from five to ten days. 

Our knowledge of the disease is based on eleven cases reported by 
general authorities. 

Etiology. — The curious clinical history of this malady impresses 
upon Senator the idea of its infectious character; the investigations, 
however, failed to determine the existence of any other bacillus than 
one similar to the staphylococcus albus, and small numbers of the 
streptococcus. 

We accept its clinical history as evidencing the fact that it is due 
to a blood poison of a virulent character, the source of which must be, 
for the present, regarded as somewhat speculative. That it is an 
entirely distinct affection from erysipelas must be accepted, on the 
ground not only of its clinical history, but in the absence of any evi- 
dence of a contagious source of the disease. 

In one or two instances, there may possibly have been a local 
cause for the affection, in the form of a mild traumatism. Thus, in 
Senator's first case, the attack seemed to come on almost immediately 
upon taking a glass of cold beer when overheated, while in one of 
Landgraf's it followed soon after the deglutition of a somewhat large 
bolus of food. We thus have suggested, perhaps, an analog} 7 between 
this affection and that rare malady, phlegmonous gastritis, which, as 
we know, arises from apparently trivial exciting causes. 

The disease belongs to adult life, all the cases reported occurring 
between the ages of twenty-three and fifty-eight, and generally in 
individuals in apparently perfect health. 

Pathology. — The primary stage seems to consist in an active 
acute inflammation, starting usually on one side of the oro-pharynx. 
This rapidly degenerates into a purulent infiltration, involving the 
deep layers of the mucous membrane. This pus infiltration seems to 



400 DISEASES OF THE FAUCES. 

remain a pus infiltration to the end, in that in no instance has there 
been recorded any evidence of abscess formation in the tissues origi- 
nally affected. The extension of the purulent infiltration seems to 
make its way along the great vessels, with a more marked tendency 
to extend downward than in any other direction. While the local 
disease of the pharynx changes rapidly into a purulent infiltration, 
this does not seem to extend along the mucous channels, as such, 
although there extends down the oesophagus, and into the stomach, 
and even into the intestines, a very active inflammatory process, 
verging on a proliferative inflammation. The same process, involv- 
ing the air passages, takes on a somewhat cedematous character, 
giving rise to serous infiltration, together with active hyperemia, in- 
volving the more loosely connected mucous membrane of the epi- 
glottis, the ary-epiglottic folds, and the ventricular bands, while in 
other portions, as in the trachea and bronchi, the process still remains 
an acute inflammatory catarrh. The morbid process, however, in the 
mucous membrane, whether in the air or food tract, is a low grade of 
inflammatory action, in which the venous hyperemia is prominent, 
giving a dull red, purplish hue to the membrane, and the same is true 
of the morbid process which is met with in the liver, spleen, and 
kidneys. Apparently as a secondary effect of the pus infiltration of 
the pharynx, we have the lymphatic glands of the neck, either on 
one or both sides, much swollen and infiltrated, while the cellular 
tissue also is infiltrated to such an extent in many instances, as to 
cause a swelling of sufficient size to fill up completely the angle be- 
tween the jaw and the neck. In rare instances this extends down as 
far as the shoulder. This infiltration is of an inflammatory char- 
acter, rather than suppurative, except so far as it extends along the 
great vessels of the neck. The morbid process in the pharynx, in 
nearly every case, has commenced on one side, and curiously enough, 
this has been usually the left, although in some instances it seems to 
have been bilateral. Commencing unilaterally it rapidly develops to 
such an extent as to involve both sides. 

Symptomatology. — The onset of the disease, in every case, seems 
to be quite abrupt, the first sensation usually experienced by the 
patient being a sharp pain, referable to the faucial region, especially 
marked in deglutition. The pain is of a lancinating character, and 
simulates the feeling of a foreign body lodged in the throat. This 
may last from twelve to twenty-four hours, when there is an access of 
febrile movement, characterized by chilly sensations, pains in the 
bones, loss of appetite, and general malaise. The local symptoms in 
the throat now become more severe in character, the inflammatory 
process in the pharynx increasing in a marked degree so as to render 



ACUTE INFECTIOUS PHLEGMON OF THE PHARYNX. 401 

deglutition, even at this period of the attack, exceedingly difficult, 
while the morbid process extends to the mucous membrane of both 
the oesophagus and air tract. At the same time the septic character 
of the disease is manifested by an involvement of the lymphatics, 
primarily of the side affected, which is followed very soon by a simi- 
lar infiltration of the lymphatics of the other side. This swelling of 
the tissues of the neck may attain to a considerable size, giviug rise 
to a somewhat hard, brawny tumefaction, not unlike that of a diffuse 
cellulitis, although the skin is not usually discolored. The febrile 
movement assumes rapidly a very grave type, in that the temperature 
may rise to 103° F. or more, on the second day, while the evidence of 
the marked systemic invasion is shown by the occurrence in nearly 
all the cases of more or less well-marked delirium at this stage of the 
attack. The pulse becomes weak, thready, and exceedingly rapid; 
indeed, the whole aspect of the attack, as a rule, bj the second, or, at 
the latest, by the third day, would seem to show that the system has 
been invaded by some acute blood poison of an infectious character. 

As the local morbid process extends into the air passages, it gives 
rise to an cedematous infiltration of the more loosely attached areas 
of mucous membrane in the larynx, causing marked dyspnoea, while 
its further extension into the bronchial tubes is evidenced by the 
secretion of mucus or muco-pus. The voice, also, early becomes 
affected, assuming a peculiar piping character. 

The morbid process also extends to the intestinal tract, and may 
cause profuse diarrhoea. 

Albuminuria seemed to occur in the majority of the cases in which 
the examination was made, which is to be explained by the parenchy- 
matous character of the infiammation occurring in the kidneys. 

As before stated, the inflammatory process in the pharynx devel- 
ops into a purulent infiltration comparatively early in the disease. 
This, however, does not seem to extend to the mucous membrane of 
the air passages, but makes its way along the course of the great ves- 
sels. The mediastinum was invaded in one case, pleurisy supervened 
in another. Dyspnoea is usually a prominent symptom at the onset 
of the disease. A scarlatina-like eruption has been known to occur, 
as have swelling and pain of the joints. 

The onset of the disease seems never to have been marked by a 
decided chill, but rather by obscure chilly sensations, which continue 
during the progress of the affection. 

The subsequent development of the malady varies only according 
to the areas invaded by the local inflammatory process, while the 
systemic symptoms, as evidenced by the febrile movement and gen- 
eral prostration, continue unchanged to the end, delirium becoming, 
26 



402 DISEASES OF THE FAUCES. 

perhaps, more active and the general failure of the vital powers being 
noticeable. In several of the cases reported, the fatal termination 
seems to have been preceded by an apparent amelioration of all the 
symptoms, both general and local. 

Diagnosis. — There is nothing in the morbid appearance on inspec- 
tion of the fauces at the onset of this affection, to give warning of 
the exceedingly grave malady with which we have to deal. The diag- 
nosis, therefore, must be based on the rapid development of a phleg- 
monous character in the local morbid process, together with the grave 
constitutional symptoms which occur early in the history of the dis- 
ease. In no single instance, so far as I know, has the character of 
this affection been recognized on inspection before dangerous symp- 
toms set in; nor, with the knowledge already gained from the few 
cases recorded in literature, is it possible to establish a diagnosis 
merely from local inspection at the commencement of the attack. 
Certain local appearances may be recognized as indicative of septic 
disease, the most prominent of these, perhaps, being the peculiar color 
of the membrane, which is of a dark red, verging on a purplish hue, 
in connection with an active, acute inflammation. The surface of the 
membrane, also, is of a dull, somewhat opaque appearance, in con- 
trast to the glassy, semi-translucent condition met with in ordinary 
idiopathic inflammation. 

The peculiar character of the pain which accompanies it may per- 
haps be suggestive, in that it occurs mainly on deglutition and is of 
a sharp, lancinating character. The swelling of the membrane, also, 
may be an important diagnostic factor, as usually occurring on but 
one side and being marked in character, the membrane projecting to 
a considerable extent forward into the pharyngeal cavity. The rapid 
extension of the inflammation should also excite apprehension. 

Pain on pressure is always present. The early occurrence of the 
profound impression on the general system, as evidenced by the rapid 
and thready pulse, high fever, and especially the delirium, constitute 
symptoms which, when manifested, should immediately suggest this 
disease, especially when taken in connection with the occurrence of 
engorgement of the neck, this tumefaction being of a diffuse char- 
acter, and one in which the individual glands cannot be recognized. 

The presence of albuminuria, as well as enlargement of the spleen 
and liver, should be regarded as somewhat corroborative symptoms. 

Prognosis. — The disease is an exceedingly fatal one, and runs its 
course in a comparatively short time. The only recovery which has 
yet been reported was in a case observed by Hager in a man aged 
thirty -nine, in whom the disease lasted forty-one days. In all the 
other cases death ensued, usually on the fifth or sixth day. 



ACUTE INFECTIOUS PHLEGMON OF THE PHARYNX. 403 

Treatment. — We know of no remedy whose action seems in any 
way to arrest the progress or to ameliorate the virulence of the infec- 
tive poison which is the undoubted source of the disease. 

The scarification of the pharyngeal mucous membrane, followed 
by the application of nitrate of silver to the open wounds, would 
commend itself in the early stage of the disease as offering fair hope 
of mitigating the severity of the attack, if not of arresting its progress. 

In Hager's case which recovered at the end of forty-one days, the 
treatment was essentially symptomatic, although the drugs to which 
he attributed the best results were antipyrin in controlling the 
febrile movement and brandy freely used to sustain the vital powers. 

It would seem that the tendency to death is due to the blood- 
poison, rather than to any direct or remote results of the local in- 
flammatory process. To combat this condition, the free use of 
stimulants is demanded in connection with antipyretics, creosote, 
quinine, and other drugs of this character, as may be indicated. 



CHAPTER LV. 
KETKO-PHABYNGEAL ABSCESS. 

This name is used to designate a phlegmonous inflammation in 
the lower pharynx, which results in the formation of an abscess. 
The definition might also embrace a pharyngeal quinsy ; the former, 
however, has no connection with the rheumatic habit, as is the rule 
in quinsy. In acute infectious phlegmon we meet with pus formation 
in this region, but this is invariably due to a specific poison. 

Etiology. — We are compelled to embrace under this classification 
a series of disorders which apparently have no direct clinical connec- 
tion. The teaching that a retro-pharyngeal abscess is nearly always 
due to caries of one of the vertebrae or of the occipital bone, has 
received general acceptance up to comparatively recent times. Now, 
however, we recognize the fact that it really occurs more frequently 
as an idiopathic affection. It may also be as a sequel of one of the 
exanthems, or the result of a burrowing of pus from neighboring 
parts. Bokai, who has made a most elaborate study of the disease, 
covering an analysis of two hundred and four cases, finds that one 
hundred and seventy-nine were idiopathic. 

Further than this it is exceedingly difficult to assign any definite 
cause for the disease. It occurs as a rule in healthy young children. 
It is not confined to early life, however; in my own practice I have 
seen it as late as the age of thirty-seven. An ulcerated tooth was 
supposed to be the cause in a case of Agnew's. How the burrow- 
ing of pus from caries of the spine, or the presence of foreign bodies 
in the pharynx, may lead to the formation of pharyngeal abscess is 
quite clear. 

Sex seems to exert no influence. 

Martin reports a case occurring in adult life, which seemed to be 
due to tertiary syphilis. The sequence of events appeared to be a 
suppuration of the cervical glands, and subsequently the development 
of a similar process in the lymphatics of the lower pharynx. 

We find that, when we study this disease in adult life, we are con- 
fronted with the fact that each case is somewhat unique, and that to 
establish any general rules of causation becomes impossible. In 



RETROPHARYNGEAL ABSCESS. 405 

child life, however, we meet with a very large number of cases which 
present a somewhat definite and harmonious clinical history, in which 
the causation of the disease can be estimated with a certain amount 
of definiteness. 

Among the local causes, then, we recognize the presence of foreign 
bodies, the local inflammatory changes in the exanthemata, such as 
measles, scarlet fever, and diphtheria. Lewandowsky thinks that in 
scarlet fever the pharyngeal abscess may be traced to a diseased con- 
dition of the nose. Whether the irritation be direct from the pharyn- 
geal lymphatics or indirect from the nasal lymphatics, the conclusion 
seems fairly well established that the pharyngeal abscess arises pri- 
marily from inflammation and suppuration of the lymphatic structure. 
In the same manner, I think, we may find the primary source of 
irritation in a suppurative inflammation of the middle ear, as in the 
case reported by Wiel. 

Pathology. — In forming an estimate of the true pathological 
changes which occur in a pharyngeal abscess, we must recognize the 
clinical fact that in adult life an abscess belongs essentially to the 
cellular tissue, while in child life a suppurative inflammation in the 
areolar tissue is comparatively rare. Furthermore, in child life the 
lymphatic tissues are in an active state of development, and therefore 
prone to take on diseased action ; in adult life, on the other hand, these 
tissues shows much less liability to morbid changes. 

As a matter of fact we find that the morbid process in retro- 
pharyngeal abscess in adult life differs in no marked degree from that 
which we describe in connection with an ordinary quinsy. When we 
come to study the disease in child life, however, we must adopt the 
view advocated by Bokai, that the primary seat of morbid change 
occurs in the lymphatic structures of the pharynx. The prominent 
clinical fact which seems to point to the lymphatic origin of the 
abscess is the slow development of the suppurative process, in con- 
tradistinction to the somewhat rapid development of the same process 
in the cellular tissues. In children the abscess generally forms either 
in one or the other side of the lower pharynx, and in rare instances 
in the central portion. Ordinarily the abscess forms in the visible 
portion of the oro-pharynx, rarely if ever extending above the border 
of the soft palate ; although instances have been reported in which 
it extended downward behind the oesophagus. Thus, in one case it 
extended down to the level of the first and in another as far as the 
third dorsal vertebra. In a third case the pus made its way through 
the tissues of the neck, and opened at the level of the clavicle. These, 
of course, refer to instances of the disease in childhood. In adult 
life, if the disease be idiopathic, it usually involves the whole of the 



406 DISEASES OF THE FAUCES. 

retropharyngeal wall. When, however, it is due to the presence of 
a foreign body the abscess is actively progressive, and extends not 
only rapidly but uninterruptedly. 

Symptomatology. — The clinical history and symptoms of a phar- 
yngeal abscess in adult life and young children differ in a marked 
degree. 

In Children. — The disease, as we have already seen, at this period 
of life is to be regarded as one of the manifestations of the strumous 
diathesis. Its development is somewhat insidious ; there is loss of 
appetite, restlessness, a slight cough, but no prominent local symp- 
toms. This may last for several days, when some evidences of throat 
trouble are shown in the slight cough, followed soon by a peculiar 
character of the voice, which Beigenier describes as a cri de canard." 
Deglutition also becomes not only painful but even impossible ; the 
child refuses the breast on account of its inability to swallow. Dysp- 
noea becomes a prominent symptom in the majority of cases, sooner 
or later, owing to the phlegmon pressing upon the posterior wall of 
the larynx, or overhanging it in such a way as to interfere with the 
entrance of air, and is closely followed by cyanosis, which is usually 
inspiratory, although when the tumor attains considerable size there 
may be interference with both movements of respiration. 

So insidious is the onset of the disease in certain cases that 
attention may not be called to the existence of the localized dis- 
ease in the pharynx for from four to six days, or even longer, after 
the commencement of the attack. In other cases, however, the very 
first manifestations of the disease may give rise to such prominent 
local symptoms as to call immediate attention to the pharynx. This 
is dependent, of course, mainly on the locality of the abscess. 

In certain cases the abscess develops as low as the post-cesopha- 
geal space, and in such case, whereas deglutition is accomplished with 
comparative ease, dyspnoea becomes a somewhat notable symptom, 
being both inspiratory and expiratory. The position in which the 
child holds the head inclined forward, or bent to the opposite side, 
constitutes a symptom of certain diagnostic value; indeed, Albert 
goes so far as to regard this as almost pathognomonic. 

In Adult Life. — When a retro-pharyngeal abscess develops in an 
adult, it makes itself known at its onset, as a rule, by well-marked 
symptoms, which call attention immediately to the existence of some 
morbid lesion in the faucial region. This probably is due to the fact 
already noted, that at this period of life the morbid process involves 
the cellular tissue. We know of no case in which in an adult it has 
been caused by spinal caries. Hence we regard it as an acute inflam- 
matory process, of the nature of quinsy, without rheumatic taint as a 



RETROPHARYNGEAL ABSCESS. 407 

predisposing cause. The first symptom, therefore, to which it gives 
rise will consist of pain referable to the faucial region, aggravated 
during deglutition. Moreover, its onset is marked by notable gen- 
eral disturbance of a febrile character (101° to 102° F.), differing from 
the process in child life, when evidences of acute febrile movement 
are usually absent at the onset, although, as the disease progresses, 
a low form of fever sets in. The symptoms, of course, vary somewhat 
according to the locality of the abscess. In a case reported by 
McCoy, the phlegmon, developing in the pharyngeal wall, extended 
finally from the level of the larynx to the pharyngeal vault, giving 
rise not only to difficult deglutition, but to regurgitation of food; 
this, however, is not common. These pains are deep-seated and 
constant, and increase with the development of the disease, until the 
abscess ruptures. Dyspncea, so. far as I know, is rarely if ever pres- 
ent, and the general health is not seriously impaired. 

Diagnosis. — In adult life, we find the appearances of ordinary 
phlegmon produced, which, if the abscess exists on either side of the 
fauces, will give rise to an asymmetrical condition of the parts with 
the characteristic tumefaction; the bulging portion presenting a 
bright red, somewhat glazed aspect, with the peculiar contour of 
abscess formation. The diagnosis, of course, may be established by 
palpation. Additional information is obtained by the impact of the 
probe, in that the small area immediately about the point of contact 
becomes exsanguinated or bleached out on pressing the probe into 
the parts, the blood returning slowly after the pressure is relieved. 
This, I think, is peculiarly characteristic of phlegmonous inflamma- 
tion, especially after the abscess has formed. 

In child life, a retro-pharyngeal abscess, as we have seen, is not 
the result of phlegmonous inflammation, but is of a more chronic 
character ; hence the formation of pus is not attended with any active 
localized inflammation; in fact, the tissues about the abscess, and 
the mucous membrane covering it, present very slight evidences of 
the morbid process. Hence our recognition of the existence of the 
abscess must be based entirely on the asymmetrical condition of the 
parts, and the recognition of a pouching tumor encroaching upon 
the lumen of the pharynx. Having established by ocular inspection 
the existence of this tumefaction, its fluid character is recognized by 
palpation and probing. 

The above refers to the ordinary type of cases ; the diagnosis, 
however, is by no means so easy in those exceptional cases which 
present a different array of symptoms. The existence of an abscess 
in the cervical region should always suggest the possibility of a simi- 
lar condition of things in the pharynx, and lead us to make a thorough 



408 DTSEASES OF THE FAUCES. 

inspection of tiie latter region. This is not confined to the disease 
as it occurs in children. 

There are no important points to be made in connection with the 
question of differential diagnosis, although we are usually informed 
of the danger of mistaking a retro-pharyngeal abscess in a child for 
croup, bronchitis, or oedema of the glottis. 

A phlegmonous abscess in adult life presents no special difficulties 
or dangers of mistaken diagnosis, other than those to be discussed in 
connection with the subject of quinsy. Mention should, however, be 
made in this connection of the possible danger of mistaking an aneu- 
rism for an abscess, as in a case reported by Duke in which an aneu- 
rism, pouching into the pharynx, was opened in search of pus, with 
the result of almost fatal hemorrhage, although the patient's life was 
eventually saved by ligature of the common carotid artery. 

Course and Prognosis. — When the abscess is the result of a 
phlegmonous process, it runs its course in from five to ten days, dis- 
charging itself spontaneously unless it has been previously opened 
by surgical interference. It involves no special dangers to life, and 
is attended with no grave complications, other than those discussed 
in the chapter on quinsy. If the disease be due to a suppurative 
process in the lymphatic structures of the pharynx, it runs a some- 
what chronic course, its duration extending usually from two to four 
weeks. And whereas the mere existence of this lesion is an indication 
of the strumous habit which should render the prognosis somewhat 
grave, as a rule these cases do not succumb, provided the character of 
the disease is recognized ; and while the disease in itself does not tend 
necessarily to a fatal result, complications may arise to hasten this 
end. In cases reported, the immediate cause of death was oedema of 
the glottis and suffocation from spontaneous rupture of the abscess, 
the pus making its way into the air passages ; and erosion of the 
large arteries of the neck by the burrowing of the pus. 

When retro-pharyngeal abscess occurs in young children of stru- 
mous habit, pulmonary troubles frequently constitute a very serious 
complication of the disease, especially when there is respiratory 
obstruction. Temoin has reported two instances in which the imme- 
diate cause of death was broncho-pneumonia. Bokai seems to think 
that this complication arises from the penetration of pus into the air 
passages, although quite as rational an explanation would seem to 
be in the respiratory obstruction, this acting to produce pulmonary 
lesions in much the same way as an attack of membranous croup. 

(Edema of the glottis is also a frequent complication, though it 
is not necessarily fatal. 

We find, therefore, that while the affection runs a somewhat pro- 



RETRO- PHARYNGEAL ABSCESS. 409 

tractecl course in instances of lymphatic abscess, death is not a fore- 
gone conclusion except from complications that may occur, or in the 
failure to make a diagnosis. 

In those cases in which the disease is symptomatic of caries of 
the vertebrae, the affection develops rather insidiously, and extends 
slowly by burrowing along the course of the vertebral column, and 
may extend down behind the oesophagus as far as the second or third 
dorsal vertebra, as in a case reported by Kipley. 

In one observed by Mercier, the caries was known to have been 
present eighteen months, whereas the pharyngeal abscess had existed 
only a few weeks. The caries in this case was due to an injury, 
and the child eventually recovered. In a case reported by Chapin, 
the disease lasted six months, the abscess forming apparently early 
in its history, and yet it was never visible in the pharynx and was 
discovered only post mortem. 

The prognosis in these cases is usually fatal, the caries of the 
spine being dependent upon a strumous condition, which renders the 
pharyngeal abscess merely symptomatic and complicative ; the only 
instance of recovery that I recall being that of Mercier, in which the 
vertebral disease was of traumatic origin. The immediate cause of 
death in these patients is practically the same as in the lymphatic 
abscesses, either by inanition, suffocation, or a complicating broncho- 
pneumonia. 

Treatment. — If the abscess be of the phlegmonous character, such 
is is met with in adults, it should be evacuated as soon as the exist- 
ence of pus has been determined, or the parts scarified even before 
the pus sac has been recognized. When the disease is due to sup- 
puration of the lymphatic tissues of the pharynx, the same procedure 
should be followed. The abscess should be opened at the most 
dependent portion of the sac, but it is to be borne in mind that a large 
amount of pus pouring into the air-passages of an infant is likely to 
make its way into the larynx and trachea below, with dangerous con- 
sequences. Hence, the child should be held in an inverted position 
as soon as the pus begins to flow, in order to avoid this danger. As 
we have already seen, suppuration of the lymphatic glands of the 
pharynx is very intimately associated with a morbid condition of the 
cervical lymphatics, and is occasionally attended with a similar pro- 
cess in this region. When this latter condition exists, of course the 
opening should be made externally, and the incision carried suffi- 
ciently deep to evacuate the pus accumulation in the pharynx. Tre- 
lat made the opening completely through from the pharynx to the 
neck, thus establishing external drainage. Burckhardt goes so far 
as to advise that in all cases of retropharyngeal abscess due to sup- 



410 DISEASES OF THE FAUCES. 

puration of the lymphatics, the opening should be made externally 
through the tissues of the neck. He makes his incision along the 
anterior border of the sterno-mastoid muscle, and, crowding the 
great vessels to one side, goes on till the pus sac is reached. The 
operation is a comparatively simple one, and can easily be accom- 
plished by means of an ordinary bistoury. If the child cannot well 
be controlled otherwise, a few whiffs of chloroform should be admin- 
istered. 

If after the discharge of the pus there still remains lymphatic 
engorgement, it may be wise to make use of external applications of 
iodine, in some of its various preparations, to dissipate this. The 
main indication, however, after the evacuation of the abscess, is the 
building up of the system by the administration of tonics, the best 
of which is cod-liver oil with syrup of the iodide of iron. 

In the treatment of a disease which is dependent upon a caries of 
the vertebrae, the indications are practically the same as those already 
suggested in connection with a lymphatic abscess, viz., the early 
evacuation of the pus. It should be borne in mind, however, that 
the purulent accumulation in the pharynx is merely symptomatic 
of the graver form of disease which lies behind it, and that, while the 
local complication threatens serious danger in the way of obstructed 
respiration, dysphagia, or pulmonary trouble, the serious feature of 
the disease is a caries of the spine, which usually terminates fatally. 
We have already noticed the peculiar feature in certain cases, that the 
abscess, while not producing dysphagia, presses so far on the trachea 
as to give rise to marked dyspnoea. This would seem to suggest that 
in tracheotomy the tube should be inserted as low down as can con- 
veniently be done. 



CHAPTER LVL 

ACUTE UVULITIS. 

The pendulous portion of the velum palati may occasionally 
become the seat of an acute inflammatory process. 

Etiology. — The prominent predisposing cause lies in the size of 
the normal organ. For instance I have never seen an acute uvulitis 
in a rudimentary uvula. On the other hand, when the organ is 
broad and pendulous, it is very likely to become the seat of repeated 
attacks of acute inflammation, which are usually excited by taking 
cold. We have rather insisted heretofore on the point that repeated 
attacks of acute inflammation are really a symptom of chronic inflam- 
matory action. This is true to a certain extent of the uvula, which 
we occasionally find in a state of chronic inflammation in connection 
with chronic pharyngitis or naso-pharyngeal catarrh. 

Lennox Browne takes the ground that it frequently accompanies 
the arthritic habit and is also accompanied with disturbances of the 
digestive apparatus ; even as pharyngitis is usually associated with a 
disordered condition of the stomach. 

Probably the most frequent cause of it is an attack of quinsy, the 
cedematous uvula filling up a large portion of the space left between 
the peritonsillar abscess and the faucial wall of the opposite side. 

It frequently comes on in connection with an acute pharyngitis, 
in which case it usually develops quite early in the course of the 
attack and rapidly assumes distressing features, giving rise to pain 
on deglutition and even dyspncea with suffocative attacks. 

In a larger proportion of instances probably it occurs spontane- 
ously and without any involvement of the surrounding tissues, the 
first symptom that the patient .experiences being a sensation of a 
lump or foreign body in the fauces, followed soon by more or less 
discomfort or pain in deglutition. As the organ increases in size, it 
gives rise to an irritating cough with dyspnoea, and perhaps suffoca- 
tive attacks, dependent on the extent to which it encroaches upon the 
faucial isthmus. 

Traumatism also is an occasional source of the attack, as it may 
follow the accidental swallowing of hot water, ammonia, oxalic acid, 



412 DISEASES OF THE FAUCES. 

or other chemical irritants, and the ulcerative processes in the phar- 
ynx, especially the deep ulcers of syphilis. 

Pathology. — The changes which occur in the organ are essentially 
those of acute inflammation, in which the serous exudation of the 
second stage assumes unusual prominence.. The morbid process is 
confined also almost entirely to the mucous membrane, although the 
azygos muscle is probably infiltrated to a certain extent. 

Diagnosis. — The condition is easily recognized. On inspection 
the uvula will be seen presenting a large, rounded mass hanging 
freely into the fauces, of a bright red color where it is attached to the 
palate, and presenting all the evidences of acute inflammation. The 
lower portion of it, however, exhibits the whitish-gray, semi-translu- 
cent aspect, so characteristic of oedematous inflammation. At times, 
the tension on the mucous membrane is so great that it gives rise to 
a vascular stasis, causing the part to appear dark red or purplish. 

Prognosis. — An oedematous uvula does not give rise to anything 
more than distressing and somewhat threatening S3 mptoms at the 
time of the attack. I know of no fatal case having occurred. 

Treatment. — The first resort in all cases should be free punc- 
ture by means of a slender, sharp-pointed bistoury. These punc- 
tures, to the number of ten to twenty, if necessary, should be made 
over the whole of the organ, especially round the lower portion and 
upon its posterior surface if such can be reached. It is rarely 
necessary to penetrate more than through the superficial layers of 
the mucous membrane, to the depth of perhaps one-eighth of an inch. 
In this way there will follow a free flow of serum, with the result in 
most instances of marked and immediate relief, and the total disap- 
pearance of the oedema in the course of a few hours. Although the 
letting of blood by the puncturing is not especialty indicated, there 
is, of course, no objection to it. 

Puncturing I regard as a far better procedure than linear scarifi- 
cation. 

In aggravated cases scarification may fail to give immediate relief. 
Amputation of the uvula will give complete relief in these instances. 

In my own experience cocaine is of little avail in a well-devel- 
oped condition of oedema. « 

Chronic Uvulitis. 

We occasionally find the mucous membrane covering the uvula in 
a state of chronic inflammation, as evidenced by its reddened color 
and semi-relaxed condition. I have never seen an instance in which 
this condition was primary. It occurs most frequently in connection 



ACUTE UVULITIS. 413 

with chronic pharyngitis or chronic naso-pharyngitis. It also is met 
with in certain instances in connection with an elongated uvula. 
This is the condition which is often referred to by the term relaxed 
sore throat. It possesses no special clinical significance, gives rise 
to no symptoms which are to be directly attributed to the inflamma- 
tion of the mucous membrane, nor does it usually call for any direct 
local treatment. 



CHAPTER LVII. 
ELONGATED UYULA. 

The pendulous uvula in a healthy throat should hang freely in 
the faucial isthmus, but should not impinge upon the parts below. 
When, on the other hand, a uvula hanging from the edge of the pal- 
ate impinges upon the base of the tongue, epiglottis, or parts below, 
it should be regarded as an abnormality. 

Etiology. — I believe in most instances the condition is primarily 
congenital, but of course as a consequence of repeated attacks of in- 
flammation in later life the elongation is increased. 

Pathology. — I have never known a case in which the azygos mus- 
cle was involved in an elongated uvula. The central portion of the 
mass is made up of the white fibrous and yellow elastic tissue which 
is found in the lower portion of the normal uvula. This is traversed 
by numerous blood-vessels, while externally the mass is covered with 
healthy mucous membrane, somewhat loosely attached to the tissues 
beneath. The elongation occurs from above downward, and as the 
organ becomes elongated it maintains, as a rule, its original diameter. 
I do not think that we ever have any lateral growth in an abnormally 
long uvula. 

The length of the uvula varies of course in different persons. 

Symptomatology. — The symptoms to which this condition gives 
rise vary greatly, but there is usually a sense of irritation or tickling 
in the fauces, with the feeling of a foreign body, which the patient 
constantly endeavors to expel by hawking or clearing the throat. As 
the parts become more sensitive a cough may be set up. 

Deglutition and phonation are not notably affected; if, however, 
the organ becomes of such length as to impinge upon the larynx, a 
chronic laryngitis may be the result, in which case the voice is no- 
tably impaired. A perfect singing voice demands that every portion 
of the upper air tract shall be in a condition of health. It is easy to 
understand, therefore, how a singer might be seriously hampered by 
the existence of an abnormally long uvula. 

Attacks of suffocation or spasm of the glottis are by no means 



ELONGATED UVULA. 415 

uncommon in connection with this condition, especially in patients 
of nervous temperament. 

Tlie cough is usually dry, irritating, and persistent, and not ordi- 
narily accompanied by any expectoration unless complicated by ca- 
tarrhal inflammation in the fauces. An especial feature of the cough, 
as well as of the other symptoms is the exacerbation on lying down. 
In the recumbent position the uvula lies upon the posterior wall of 
the phar}* nx and may give rise to cough, choking attacks, or spasm 
of the glottis. 

In an interesting case which came under my observation an elon- 
gated uvula gave rise to repeated paroxysms of asthma, not of a very 
severe type, but accompanied with sibilant and sonorous bronchial 
rales. Uvulotomy gave complete relief, and there was never a recur- 
rence of the asthma. 

Diagnosis. — It would seem an exceedingly easy matter to recog- 
nize an elongated uvula on simple inspection of the fauces, and yet it 
may often be a question whether the uvula is of sufficient length to 
give rise to morbid symptoms. If any symptoms are present referable 
to the fauces, I think it quite safe to act upon the rule that the nor- 
mal length of the uvula in an adult is rarely over three-eighths of an 
inch. 

Prognosis. — This condition involves no grave danger but it is not 
a condition which tends to recovery. To one accustomed to use the 
higher powers of the voice, viz., in singing or recitation, the progno- 
sis as regards preservation of the voice is, I think, somewhat unfavor- 
able. The constant presence of an abnormally long uvula not only 
temporarily impairs the singing voice, but tends to give rise to mor- 
bid changes in the air passages below, under the influence of which 
not only does this impairment increase, but a serious danger of 
permanent loss is threatened. 

Treatment. — No local applications are of any avail whatever in 
the treatment of this affection. The only treatment that possesses 
any permanency is the removal of the superfluous portion. The 
removal of the entire organ I regard as an exceedingly unjustifiable 
and vicious practice. 

The restless movements of the uvula, together with the arching of 
the tongue, occasionally render it difficult to grasp and control the 
organ. This seems to have suggested to Bell the construction of the 
guillotine, which consisted of a flat plate of metal with a rounded 
opening in its distal extremity, upon which a blade was made to slide. 
As soon as the uvula fell into the fenestra, the blade was driven home 
by a quick movement and the organ cut through before it was 
retracted by the palatal muscles. 



416 DISEASES OF THE FAUCES. 

Mackenzie has modified this instrument by adding a simple device 
for seizing the severed portion, while Elsberg constructed an instru- 
ment on the same general principles which acted by means of a 
spring; the instrument being placed in situ and the blade being 
drawn back, it was brought into play by simply touching a trigger. 

A number of different forms of scissors have been devised ; as 
a rule, these are the ordinary surgical scissors with the addition of a 
claw which shall seize and hold the cut portion of the uvula, thus 
preventing its falling into the passages below. 

Seiler and MacDonald go still further, and curve the end of one 
of the blades of the scissors to a right angle. 

These latter instruments are undoubtedly exceedingly useful, in 
that they prevent the uvula from slipping beyond the blade of the 
scissors, as may easily occur. The claw scissors should never under 
any circumstances be used ; they serve to complicate what is really 
quite a simple operation, for if one attempts to amputate a uvula 
with such an instrument without first seizing it with the forceps he 
will in most instances not only fail in his operation but will inflict 
unnecessary distress on the patient. 

I have referred to these instruments as the matter possesses a 
certain amount of interest ; and yet practically I think that no special 
instruments are required for the operation. In my own practice for 
years I have contented myself with simply seizing the tip of the 
uvula with a pair of mouse-toothed forceps held in the left hand, and 
drawing it forward on the dorsum of the tongue, cutting the redun- 
dant portion off with a pair of the ordinary curved scissors. Care 
should be exercised not to draw too vigorously upon the organ, as in 
this manner the mucous membrane is drawn down in such a way that 
after the section is made it retracts, leaving a large cut surface pro- 
truding from the tip. It is also important, I think, in making the 
section to cut from below upward and backward. In this way, after 
the excision has been made the cut surface is entirely on the posterior 
aspect of the organ. The result is that in swallowing food and liquids 
the raw surface applies itself closely to the pharyngeal wall and is 
less liable to be irritated by the ingesta. This point I regard as one 
of exceeding importance, and, as will easily be perceived, this pecu- 
liar Hue of division is not secured by the uvulotome or the claw scis- 
sors. In most instances it is necessary to depress the tongue by 
means of the spatula. This instrument is easily held in the right 
hand while the thumb and second finger of the right hand are in- 
serted in the rings of the scissors. As soon as the tip of the uvula has 
been properly seized by the forceps, the spatula is dropped and the 
scissors are brought into play. After the organ has been amputated 



ELONGATED UVULA. 417 

it is important to direct the patient to take for the remainder of the 
day no food containing salt, vinegar, pepper, or other irritating sub- 
stance, and in addition to carry a small piece of gum arabic or elm 
bark in the mouth. In case of children, gum drops or fresh marsh 
mallows answer an equally good purpose. 

If the organ is unnecessarily mutilated in amputation, the patient 
will suffer with a severe sore throat for days. I think, however, that 
in the majority of cases, if the operation is properly done, the dis- 
comfort which follows it need not last for more than from twelve to 
twenty-four hours. 

Hemorrhage after Uvulotomy. — Uvulotomy is to be regarded as 
an exceedingly simple operation and one practically unattended with 
danger; and yet dangerous hemorrhage has followed the operation 
in a few reported cases. 

It is not easy, however, to understand how hemorrhage from 
uvulotomy can be troublesome or difficult to control if the operation 
has been done at the proper point, viz. , at a distance of three-eighths 
to half an inch below the border of the palate. 

In the cases in which the whole organ was removed, the hemor- 
rhage persisted for twenty-four hours. In those cases in which it is 
stated that only a portion of the organ was removed, the hemorrhage 
was as a rule readily controlled. 

I think that in case hemorrhage follows uvulotomy, the ordinary 
haemostatics are not to be depended upon, and our most reliable 
resort will be in the use of a clamp applied to the stump. 

Morgan has devised an instrument on the principle of the serre- 
fine for use in these cases. 

Speaking generally, it would seem that hemorrhage might be 
avoided by performing the amputation with the snare. Morgan ad- 
vises the snare, on the ground that a better stump will be left. I am 
disposed to think, however, that the bruising of the tissues which 
accompanies the use of this instrument would give rise to a rather 
distressing sore throat. 

While a serious objection to the complete removal of the uvula 
lies in the danger of hemorrhage, Shurley makes a still further point 
that one of the functions of this organ lies in supporting the palate 
during phonation by resting upon the base of the tongue ; this sup- 
port, therefore, is abolished in its complete removal, resulting in an 
additional labor and consequent fatigue to the palatal muscles in the 
use of the voice. 
27 



CHAPTER LVIII. 

QUINSY, OE PERITONSILLAR ABSCESS. 

The term quinsy is merely a corruption of the term cynanclie, so 
extensively used in older medical literature to designate the various 
diseased conditions of the fauces which were characterized by an 
angina or obstruction of the parts. The term quinsy is here re- 
tained on account of its very general adoption and usage in literature. 

We may define a quinsy as an acute inflammation of the tissues 
immediately surrounding one or the other of the faucial tonsils, which 
rapidly assumes a phlegmonous character and results usually in an 
abscess. In the large majority of cases the soft tissues immediately 
in front of the tonsil and the soft palate are involved. In others the 
inflammation develops behind the tonsil, and, extending backward 
and downward, an abscess is formed in the lateral walls of the lower 
pharynx. In still rarer instances the morbid process seems to start 
in the tissues immediately beneath the tonsil, giving rise to a suppu- 
rative process, which results in the formation of an abscess in this 
region, the pus making its escape directly through the deep layer of 
the tonsil into one of its crypts, and finally escaping on the surface 
of the organ itself. The point which I desire to emphasize is that 
this inflammation does not take place in the tonsil, but rather in 
the peritonsillar areolar tissue. During the course of the morbid 
process, however, the tonsil itself becomes somewhat involved in the 
inflammatory action, and is also elevated or crowded out from its 
bed in such a way as to give rise to the impression that the tonsil is 
the seat of disease. Hence, the name acute tonsillitis is often given 
to it. 

Etiology. — This affection belongs essentiallv to the middle period 
of life. 

That it should occur far more frequently in males than in females 
is easily understood, in that its common exciting cause is taking 
cold, to which men are necessarily much more exposed. The season 
has a very marked influence upon its development, for the same 
reason, viz., that, resulting from exposure to cold, it is far more likely 
to occur during the spring and fall months, when all diseases which 



QUINSY, OR PERITONSILLAR ABSCESS. 419 

follow exposure are more prevalent. Mackenzie shows that in eleven 
hundred and seventy-six cases seen in a year in the London Throat 
Hospital, six hundred and one occurred in July, August, September, 
and October. 

It is a matter of almost universal observation that it is an hered- 
itary disease and runs in families. 

It occurs rather in the lower walks of life, and among those com- 
pelled to live an outdoor life and labor in the open air. 

We know of no exciting cause of the attack, other than an expos- 
ure to cold. Our interest, however, in the clinical history of the dis- 
ease lies more largely in the active predisposing causes, and of these 
we must undoubtedly place first and above all the rheumatic habit. 
Indeed, I am disposed to make the assertion that a suppurative 
inflammation in the cellular tissue surrounding the faucial tonsil, in 
probably nine cases out of ten, should be regarded as a manifestation 
of rheumatism. This idea is by no means a new one, for while it 
has not received definite expression in the older literature of throat 
diseases, the reputation which the preparations of guaiac have ob- 
tained for the treatment of this affection, in long years past, must be 
accepted as a recognition of the systemic character of the disease, 
although th;s drug was used somewhat empirically. 

That the existence of enlarged tonsils undoubtedly invites the 
phlegmonous inflammation to the surrounding tissues is a matter of 
very frequent clinical observation. I do not, however, regard an 
inert hypertrophied tonsil as so actively predisposing to quinsy as 
the subacute tonsillitis which not infrequently occurs in the organ. 

An attack of acute follicular tonsillitis also very frequently pre- 
cedes the phlegmonous inflammation, though in these cases I think 
we must recognize a particular predisposing cause in a rheumatic 
habit, or some other general dyscrasia, in that an acute follicular 
tonsillitis does not and cannot develop a quinsy without some par- 
ticular predisposing cause. In the same manner we occasionally see 
an attack of scarlet fever or measles, or other of the exanthemata, 
give rise to an attack of quinsy. 

In addition to the above, there are undoubtedly many cases which 
apparently develop spontaneously. We rnay simply say that impaired 
general health, irregularity of life, vicious hygienic surroundings, 
and other causes of this nature predispose to the disease. 

Pathology. — The special pathological process which character- 
izes the development and progress of an attack of quinsy presents no 
especial features, so far as we know, which differ in any notable de- 
gree from the ordinary suppurative processes which are met with as 
occurring in the cellular tissue of any portion of the body. 



420 DISEASES OF THE FAUCES. 

The primary seat of the phlegmon is usually in the cellular tissue 
immediately above the upper border of the tonsil, in which case the 
tumefaction extends not only beneath the tonsil, but into the tissues 
of the soft palate; the centre of induration, after the phlegmon is 
fully developed, usually pointing nearly midway between the upper 
border of the tonsil and the side of the uvula, at its base. In other 
instances we find the centre of phlegmon developing apparently in 
the cellular tissues at the lower and posterior border of the tonsil, 
the inflammation in this case extending backward and downward, 
giving rise to a somewhat elongated or spindle-shaped phlegmon 
which extends down the posterior wall of the pharynx, along its lat- 
eral border. This may reach as far as the orifice of the oesophagus. 
In this case the phlegmon usually tends to point as low down as the 
level of the epiglottis, or even below it. Another locality in which 
the phlegmon may develop is in the tissues immediately beneath the 
tonsil. In this case the tonsil is lifted bodily from its bed, while the 
centre of suppuration develops in the structures beneath the tonsil, 
the escape of pus being usually into one of its crypts. In other in- 
stances we find the inflammatory process showing its greatest activity 
in the posterior pillars of the fauces, giving rise to a somewhat elon- 
gated phlegmon, which, however, usually extends no farther than the 
base of the tongue. In an analysis of 133 cases of quinsy under my 
care, the phlegmon occurred in the soft palate in 115 cases, in one or 
the other of the posterior pillars of the fauces in 11 cases, while in 
2 the abscess developed beneath the tonsil, and discharged upon its 
surface through one of its crypts, and in two cases the posterior wall 
of the pharynx was involved. 

The suppurative process in these cases usually expends itself in 
developing an abscess, which tends somewhat to extend in all direc- 
tions around its original starting-point. The pus from a tonsillar 
abscess has been known to make its way into the cellular tissues of the 
neck as far down as the level of the clavicle. The question of course 
arises in connection with the latter cases, whether the disease may not 
have been acute infectious phlegmon, although in the latter disease 
we meet with suppurative inflammation rather than abscess formation. 

As a complicating pathological lesion, a number of cases have 
been observed in which thrombosis occurred in the neighboring veins, 
in connection with pyaemia. 

Symptomatology. — The attack is usually ushered in by a chill, or 
in rarer instances by well-marked chilly sensations. This is soon 
followed by a general febrile disturbance, the headache frequently 
being of an unusually severe type. The temperature at the onset of 
the attack reaches 102^-° or 103° F., in rare instances 105° F. 



QUINSY, OR PERITONSILLAR ABSCESS. 421 

Following these symptoms there is deep-seated discomfort in the 
fauces, referable usually to one side. This soon develops into a dis- 
tinct boring pain, which is constantly present and aggravated by 
deglutition. It may persist for twenty -four to thirty-six hours, per- 
haps, before evidences of tumefaction set in, although usually the 
swelling occurs almost immediately. The localized swelling de- 
velops rather rapidly and the normal lumen of the fauces is notably 
encroached upon. Usually, at the end of twenty-four to thirty-six 
hours deglutition is almost impossible. The local inflammation 
causes an infiltration of the muscles of the soft palate and pharynx, 
so that their contractility is to a large extent destroyed and swallow- 
ing of solid food is impossible The mucous membrane covering the 
parts also becomes infiltrated, and the soft palate, and especially the 
uvula, becomes cedematous and increases the painful symptoms. At 
the end of twenty -four to thirty-six hours usually, a deep, throbbing, 
boring pain, which at times is almost unbearable, sets in. It is usually 
referable to the faucial region, though it courses up toward the ear 
and is frequently referred to that organ. As the result of the local- 
ized tumefaction the whole mucous membrane of the fauces is involved 
in a catarrhal inflammation with hypersecretion. The mucus accu- 
mulates in the fauces, the patient being unable to expel it owing to 
the semi-paralyzed condition of the faucial muscles. The voice is 
thick and muffled, and articulation difficult. Normal nasal respira- 
tion is interfered with and the senses of smell and taste are to a large 
extent abolished. The patient at this stage presents a picture of 
distress. He sits with his body bent forward, avoiding any move- 
ments of the neck, while the head is inclined forward to allow the 
saliva to drop from the mouth, as sw r allowing is almost impossible 
and very painful. Indeed, the whole aspect of a case of quinsy, when 
the phlegmon is fully developed in the fauces, with the expression of 
pain and suffering in the face, the heavy and sleepless eyes, and open 
mouth with the dripping saliva, presents a picture of misery which is 
striking and characteristic. 

The symptoms above described are usually met with in connection 
with that form of quinsy which develops in the soft palate and con- 
fines itself to one side. The symptoms, as we see, are largely due to 
the existence of acute phlegmonous inflammation in the fauces. In 
other words, they give rise to localized pain and interfere with the 
normal functional movements of the parts. When the quinsy de- 
velops on both sides, we meet with an aggravation of all the symp- 
toms detailed above, with the addition that not only deglutition but 
respiration is interfered with. In adults this interference with 
respiration is not always a prominent symptom, but in young people 



422 DISEASES OF THE FAUCES. 

there is danger of suffocation in double quinsy. When the tumor 
develops in one of the posterior pillars of the fauces, or in the lateral 
wall of the lower pharynx, it does not assume such large proportions, 
as a rule, as when it occurs in the soft palate. The pain, however, 
is usually quite as severe, if not worse, as is also interference with 
deglutition. Furthermore, the duration of the disease here is much 
longer than where it is met with in the softer tissues above. This is 
probably due to the fact that, while suppuration occurs quite as early 
in one region as the other, the abscess makes its way much more 
slowly to the surface through the denser tissues of the pharynx than 
through the soft tissues of the palate. The long fusiform phlegmon 
which characterizes a quinsy in the lateral wall of the lower pharynx 
may extend down, as before stated, as far as the orifice of the oeso- 
phagus, or may assume such proportions as to crowd upon the 
lateral wall of the larynx and produce a distressing dyspnoea. Of 
three cases of this form of quinsy which have come under my own 
personal observation, in one of them tracheotomy had become almost 
imperative, when I finally succeeded in evacuating the pus a few 
lines above the orifice of the oesophagus. The dyspnoea in this case 
was not due to any secondary involvement of the larynx by cede- 
matous swelling, but solely to the mechanical pressure of the 
phlegmon. 

A quinsy developing in the lower pharynx is, so far as my experi- 
ence extends, unilateral, nor do I know of a case of double quinsy in 
this region having been reported. 

When the phlegmon develops in one of the posterior pillars of 
the fauces, it does not usually assume large proportions and the 
symptoms are correspondingly mild. The pain, however, is usually 
very severe, and the sufferings of the patient, so long as it lasts, 
are exceedingly distressing. 

Diagnosis. — At the onset of the attack, there is nothing in the 
local appearances which renders it possible to make a diagnosis by 
mere ocular inspection. At the end of from twelve to twenty-four 
hours, however, the local appearances are such as to render the diag- 
nosis comparatively easy. On inspection, it will be seen that the 
parts present all the characteristic appearances of an active acute 
phlegmonous inflammation. The prominent feature is the swelling 
distorting the fauces and impairing its usually symmetrical appear- 
ance. The tonsil itself is the seat of a mild inflammation, while it is 
pressed forward and inward by the swelling beneath it. The activity 
of the inflammatory process, however, is evidenced by the appearance 
of the soft palate or the parts immediately above the tonsil. This 
presents a swollen appearance, while its color is of a distinctively 



QUINSY, OR PERITONSILLAR ABSCESS. 423 

bright red tinge, verging on a purplish hue. This, of course, is 
characteristic of the most frequent form of quinsy, which involves the 
cellular tissue of the soft palate. 

The most important information, however, is obtained by palpa- 
tion. By this measure, the existence of the swelling, as well as the 
presence of pus, is easily detected, the mass being felt under the tip 
of the finger as the hard, dense, and slightly elastic tumor which 
we recognize as belonging to a phlegmonous process. In those some- 
what rare instances in which the activity of the inflammatory process 
develops in the posterior pillar or in the lateral wall of the lower 
pharynx, the diagnosis must be made mainly by ocular inspection. 
The pharynx being fully exposed, the long fusiform swelling will 
show itself, lying in the one case in the posterior pillar of the fauces, 
in the other in the lateral wall of the pharynx, showing the presence 
of an acute inflammatory process, the tumefaction projecting forward 
into the faucial region. In this region, also, it is occasionally feas- 
ible to examine the parts by means of the index-finger; and when 
this is tolerated it should always be done, as affording additional 
evidence, not only of the presence of the phlegmon, but also of the 
progress which it has made toward suppuration. 

The main importance of this manipulation is in determining 
whether suppuration has set in, and, if so, the place where the ab- 
scess tends to " point." 

A certain amount of importance is attached, in the literature of 
quinsy, to the necessity of a differential diagnosis between this dis- 
ease and the faucial manifestations of the exanthemata, diphtheria, 
acute follicular tonsillitis, fibrous tumors, malignant disease, aneu- 
rism, and gangrenous tonsillitis, or syphilitic disease of the pharynx. 
It would scarcely seem probable that any of these diseases could be 
confused with an attack of quinsy ; certainly a mistake could scarcely 
occur if the i>arts are examined with sufficient care. As regards 
diphtheria and follicular tonsillitis, the existence of an exudation 
should eliminate the question of quinsy. As regards syphilitic dis- 
ease, the only form of this which could contribute to an error in 
diagnosis would be the tertiary ulcer, the inflammatory areola of 
which, with its swollen membrane, may present something like the 
appearance of phlegmonous inflammation. The existence, however, of 
the ulcerated surface should, with careful examination, be determined. 
Ulceration, of course, never occurs with quinsy. 

In the faucial manifestations of the exanthemata, the local inflam- 
matory process does not develop in a phlegmonous form ; hence these 
conditions need not be a source of error in diagnosis. 

A differential diagnosis between a quinsy and an aneurism would 



424 DISEASES OF THE FAUCES. 

seem to be a comparatively easy matter, and yet a bistoury has been 
plunged into an aneurismal tumor with a fatal result, the operator 
thinking he had a quinsy to deal with. 

As regards gangrenous tonsillitis, this is usually a superficial 
process and not attended with any notable tumefaction of the parts ; 
however, gross inspection ought in all cases to make clear the char- 
acter of such a pathological process. 

Course and Prognosis. — A quinsy usually runs its course in from 
five to ten days, according to its location and the measures of treat- 
ment which have been resorted to to curtail or arrest its progress. 
Its course is not ordinarily attended with any especial danger to life, 
although it entails very great suffering to the patient. Its progress 
results in the development of a suppurative process in the centre of 
the phlegmon, which makes its way to the surface and escapes. 
After the pus has discharged, the active inflammatory symptoms dis- 
appear rapidly, and convalescence is practically established when the 
abscess discharges, any prominent symptoms due to the local morbid 
condition disappearing at the end of twelve, or, at the utmost, twenty- 
four hours after the abscess has been evacuated. 

As a rule, I am disposed to think that we may anticipate the for- 
mation of pus at the end of the second or by the third day. Those 
cases which are long protracted ones, as when, for instance, a quinsy 
persists for ten days or two weeks, I think are due, not to the fact of 
a delayed suppuration, but to the fact that the abscess forms in 
dense tissue, and makes its way slowly to the surface. This is char- 
acteristic of those abscesses which develop in the pharyngeal wall, 
and, in a less degree, of those which develop in the posterior pillar of 
the fauces. The quinsy which runs its course most rapidly is that 
which forms in the tissues of the soft palate. The point of selection 
for superficial necrosis, or " pointing" as it is usually called, in the 
palatal abscess, is about midway between the upper border of the 
soft palate and the side of the uvula. When, however, we meet with 
a long fusiform phlegmon in the posterior pillar of the fauces or in 
the lateral walls of the lower pharynx, the abscess generally " points" 
in the more dependent portion of the tumefaction. 

While, as we have stated, a quinsy is not considered a grave dis- 
ease, and involves no serious and direct danger to life, in its regular 
progress, cases of death occasionally occur as the result of untoward 
accidents or rare complications. Perhaps the most frequent accident 
met with is when, the evacuation having been long delayed (in con- 
sequence of which the pus cavity has attained somewhat large pro- 
portions), spontaneous rupture occurs during the night and the pus 
makes its way into the air passages, causing death by asphyxia. 



QUINSY, OR PERITONSILLAR ABSCESS. 425 

Allusion has already been made in the discussion of the pathology- of 
the disease to the cases in which pyaemia set in, followed by death. 
Pyaemia, however, certainly is not a danger which we ordinarily an- 
ticipate in connection with a simple quinsy. 

In the cases in which the pus showed a tendency to burrow in the 
deeper tissues of the neck death occurred in each instance. These 
also, we have heretofore suggested, may have been instances of acute 
infectious phlegmon. 

Suffocation may occur from obstruction in the fauces. This dan- 
ger, of course, is mainly confined to children in whom the faucial 
isthmus is so narrow that a complete occlusion is by no means diffi- 
cult. In adults, interference with respiration only occurs as the 
result of a complicating cedema of the glottis or from secondary 
irritation of the laryngeal mucous membrane. 

The destructive process goes on in quinsy as long as the abscess 
is confined, destroying everything in its way, and ceasing only with 
the evacuation of the pus. In its development, necessarily, it must 
encounter blood-vessels whose walls yield to the same destructive 
influence. When such an accident occurs, the blood-vessels being 
opened, hemorrhage ensues. The arteries which may be involved 
are the tonsillar, ascending pharyngeal, and internal carotid. The 
two former are rarely if ever involved; the position and relations, 
however, of the internal carotid are such that a peritonsillar abscess 
may involve its walls in the destructive invasion and give rise to dan- 
gerous hemorrhage. The exceeding gravity of this complication is 
evidenced by the fact that almost all the cases recorded have termi- 
nated fatally. In one case the extension of the abscess resulted in 
an erosion of the facial artery, causing a fatal termination. 

Among the somewhat unusual results of a quinsy may be men- 
tioned those instances in which the acute symptoms subside and the 
case develops into one of a chronic abscess, constituting practically 
an encysted abscess, as in three cases reported by Garel, in which 
the condition persisted for several months. In one instance a cure 
occurred spontaneously, while in the other two it was effected by the 
use of the galvano-cautery. The course of these cases was marked 
by repeated attacks of retention of pus, giving rise to painful symp- 
toms for a time, after which a free discharge set in. 

Treatment. — In this, as in all acute inflammatory affections, our 
first efforts should be made in the direction of aborting the attack. 
This can, I think, not infrequently be accomplished if th,e case is 
seen sufficiently early. I do not recall, however, an instance in which 
this effort has been successful later than twenty-four hours after the 
onset of the disease, and even at this stage it is somewhat rare, 



426 DISEASES OF THE FAUCES. 

although I think that from six to twelve hours after the characteristic 
pain has been recognized in the fauces there is very fair promise of 
arresting the further progress of the inflammation by proper meas- 
ures. These have already been somewhat fully described in the 
chapter on taking cold. 

Without waiting to ascertain the effect of the attempt to abort the 
attack, the patient should immediately be put under those remedies 
which experience teaches us exercise an almost specific action in the 
control of a phlegmon in the fauces, viz., anti-rheumatic remedies. 
Salicylate of soda should be administered as combining the action of 
the acid with the well-known action of alkalies upon the rheumatic 
habit. 

Aconite aids notably in the treatment of this disease, and is there- 
fore useful as an adjuvant. 

Without waiting to observe the result of an abortive treatment, 
we immediately administer the following : 

I£ Sodii salicylates, . 5 ij. 

Aquae, ad § vi. 

M. S. One tablespoonful every hour. 

With each dose of the salicylate there should be administered, to 
an adult, one drop of Fleming's tincture of aconite. The salicylate 
should be continued during waking hours, until a notable impression 
on the local symptoms has been obtained, unless it be contraindi- 
cated by gastric disturbance or some other complicating circumstance. 
The drop doses of the tincture of aconite are to be given until the 
constitutional effect of the drug is recognized by the characteristic 
tingling of the tips of the fingers and the lips, and the numbness in 
the fauces, if this can be recognized in connection with the localized 
pain. Wlien these evidences are observed, the further administration 
of the drug is to be abandoned -permanently, as I question if this 
remedy possesses any properties which act favorably upon the fur- 
ther progress of the disease, its action being confined practically to 
controlling the morbid process at the onset of the attack and in aid- 
ing to abort it. Furthermore, while the aconite treatment is of 
unquestioned value, it is to be regarded as secondary to that by the 
salicylates. 

Green would seem to suggest that the drug is more efficacious in 
children — a point which is apparently well taken. 

The salicylates we give thoroughly well diluted, in order to avoid, 
so far as possible, any local irritation to the stomach. 

In addition to the above remedies, the patient himself should be 
supplied with a saucer of bicarbonate of soda. By simply wetting 



QUINSY, OR PERITONSILLAR ABSCESS. 427 

the forefinger and dipping it into the soda, he can plaster the drug 
quite easily over the inflamed portion of the fauces. This can be 
repeated every half-hour ; and I consider this of almost equal value 
with the internal administration of the salicylates. Clinical experi- 
ence teaches us that it not only controls the local morbid process but 
that it also serves to mitigate, in a notable degree, the severity of the 
local pain. 

The above plan of treatment, as has been suggested, is carried 
out at first in the effort to abort the disease ; but even failing this, it 
constitutes the plan of treatment which is to be still further pursued, 
even in those cases in which we fail to arrest the affection. And even 
in such a case I think we will be convinced of the beneficial action of 
these remedies, in that when suppuration occurs this process is 
hastened in a very striking manner. Certainly in a number of cases 
which have come under my own observation I have been satisfied 
that the suppuration which set in on the second day was largely the 
result of the internal medication, in that we do not usually expect 
the abscess to form so early in a case of quinsy which has not been 
markedly influenced by therapeutic measures. 

Atkinson, in laying down a specific plan for the carrying out of 
the alkaline treatment, states that "resolution is almost always 
brought about, and patients are, with scarcely a single exception, 
able to resume their duties about the fourth day." He administers 
twenty grains of the bicarbonate of potassium, together with fifteen 
grains of citric acid, in an effervescing draught every four hours, in 
connection with guaiac lozenges and tincture-of-iodine gargles, with 
mild stimulation and frequent alimentation. 

The only further question of importancce to discuss in this con- 
nection is the resort to surgical measures. From the onset of the 
attack, the fauces should be repeatedly examined with the greatest 
care, both by inspection and digital exploration. This digital ex- 
ploration should be made at least twice daily, and the evidence of 
softening and pus formation recognized, together with the point at 
which the abscess is approaching the surface. 

Having established the existence of pus by digital palpation, a 
small, sharp-pointed bistoury should be plunged boldly into the 
mass for three-eighths to half an inch, the depth of the incision being 
dependent, of course, upon the locality and the recognized danger of 
reaching large blood-vessels. In making the incision, it is important 
that it should be of sufficient size to enable the pus to escape freely. 
If pus does not flow at the first incision, a silver probe should be 
inserted through the opening and carried in different directions with 
some little force in search of the pus sac. If the flow of pus is still 



428 DISEASES OF THE FAUCES. 

not established, additional openings may be made. The parts seem 
to a certain extent to lose their resiliency, and even with a free open- 
ing the pus does not always flow readily ; hence it may become neces- 
sary to assist the flow, by means of a probe, until the cavity is 
evacuated. I have incised the phlegmon in a very large number of 
instances of quinsy, and in no case have I done it without a certain 
degree of nervousness on account of the proximity of the blood- 
vessels, and yet it seems to me that if one recognizes the true patho- 
logical condition, and has localized the suppurating point, one ought 
to feel confidence in the manipulation. When, however, we consider 
that so great a surgeon as Chassaignac, in operating upon a faucial 
phlegmon, wounded what was probably the internal carotid artery, 
necessitating a ligation of the common carotid, this would seem to 
be an accident that might happen to any one. 

The further suggestion arises, as to the propriety of the use of 
the knife before evidences of pus have been obtained. Older writers 
advocate scarification of the tonsil in this disease. It is scarcely 
necessary to say that scarification of the tonsil is not indicated. I 
am confident, however, from a number of experiences, that much 
relief may be obtained by local blood-letting. This should be accom- 
plished by a narrow, sharp-pointed knife, with which five to eight 
punctures should be made directly into the inflamed tissue, the knife 
being plunged in rather than swept across it. 

In addition to these measures, no little can be accomplished in 
the way of relieving symptoms, and adding to the comfort of the 
sufferer, by attention to certain minor details. Prominent among 
these, perhaps, is the holding of a pellet of ice in the mouth, allow- 
ing it to lie against the inflamed parts, and also swallowing small 
pieces. Browne seems to think this may aggravate the trouble, 
although usually patients find it grateful. Gargling the throat with 
water as hot as can well be borne occasionally affords a certain 
amount of relief. The use of heat or cold is to be governed by the 
sensations of the patient. As to external applications in the form of 
poultices, hot compresses, cold compresses, ointments or liniments, 
and measures of that sort, I have little confidence in them ; they add 
to the discomfort of the patient and are not to be depended upon to 
accomplish any good result. 

The local effect of cocaine at best is but superficial, and I cer- 
tainly should not regard it as a remedy to be depended upon. 

After the abscess of a quinsy has been evacuated, the whole of 
the inflammatory process subsides and the indications for treatment 
disappear. It usually leaves no sequelae which carry with them any 
indications for further therapeutical measures, unless perhaps we 



QUINSY, OR PERITONSILLAR ABSCESS. 429 

include in this category those cases in which serious hemorrhage has 
occurred. The clinical history of these cases shows that the hemor- 
rhage is apt to recur ; hence, when such an accident has happened 
the case must be watched with the greatest care, and preparations be 
made for ligating the common carotid artery. 

The clinical history of a case of quinsy, as we know, is that of 
recurrent attacks, during the spring and fall. In many cases this 
tendency disappears apparently without cause ; the patient outgrows 
the habit, as we say. The existence of enlarged tonsils we recognize 
as one of the predisposing causes of the attack ; hence it becomes our 
especial duty in all cases in which they are present to extirpate them 
if the quinsy habit exists. By this measure we do not always remove 
the habit immediately. I have not infrequently seen patients have a 
violent attack of quinsy after the removal of enlarged tonsils. I 
think, however, that the disposition to a quinsy disappears after the 
first or perhaps the second attack, following the excision of the ton- 
sils. The only other indication for general treatment consists in the 
regulation of the general habits of living. For this purpose I have 
no practical suggestion to make, other than those already discussed 
in the chapter on taking cold. As regards any course of treatment 
for rheumatism, such as by baths, mineral waters, or the internal use 
of drugs, I have no especial suggestions to advance. The connection 
between quinsy and rheumatism is thoroughly well established from 
a clinical point of view ; and if an individual with the quinsy habit 
suffers from any prominent rheumatic manifestations during the in- 
tervals or after an attack of faucial abscess, there can be no question 
as to the propriety of a course of internal medication. It has been 
my own practice in such a case to administer the salicylates for a 
period of from four to six weeks, in from ten to twenty grain doses, 
given three times daily, provided they are tolerated by the stomach. 
If contraindicated, trial may be made of the oil of wintergreen, salol, 
iodide of potash, or other antirheumatic remedies. Our main reli- 
ance, however, will be in the removal of enlarged tonsils, the correc- 
tion of other local disorder in the air passages, and the proper regu- 
lation of the habits of life. 



CHAPTER LIX. 

HYPEKTKOPHY OF THE TONSILS. 

As we have already learned, the faucial tonsils are composed 
almost entirely of that somewhat curious tissue which is especially 
liable in the earlier periods of life to become the seat of morbid 
changes, viz., the lymphatic tissue. Furthermore, when any morbid 
process fixes itself upon these structures, it ultimately results in the 
very large majority of instances in the development of a permanent 
hypertrophy. Probably in no masses of lymphatic tissue found in 
the body is hypertrophy more frequently met with than in those 
masses which are designated as the faucial tonsils. 

Etiology. — Undoubtedly the most prominent predisposing cause 
of this affection lies in that peculiar diathesis which we may call the 
lymphatic habit, which is somewhat closely related to the strumous 
diathesis. 

Recognizing, theD, the existence of a diathetic habit as causing 
the disease, this necessarily involves the further statement that it is 
hereditary. This fact is constantly taught us by clinical experience, 
in that we frequently see several cases occurring in children of the 
same family, and furthermore learn of one or both the parents having 
suffered in the same way. 

The disease is essentially one of child life, and develops some- 
what early. Probably in many instances the commencement of the 
morbid change occurs during foetal life. As a rule, however, the 
organs commence to enlarge at about the age of three or four. Many 
statistics have been published showing definitely the ages at which 
this disease is met with. These give little information, however, for 
the statistics simply show the ages at which the cases presented for 
observation. I am disposed to think that sex has little, if any, pre- 
disposing influence. 

Among the most active causes of the disease are scarlet fever, 
diphtheria, measles, and small-pox, in the order of their importance. 

Cornil very shrewdly suggests that these diseases, being infec- 
tious in character, naturally give rise to inflammation of the lym- 
phatic glands in the deep-seated structures of the fauces, and thereby 



HYPERTROPHY OF THE TONSILS. 431 

set in play forces which result in permanent hypertrophies — a pro- 
cess which is by no means liable to follow a simple catarrhal inflam- 
mation in this region. 

How large a proportion of instances of this affection follow the 
infectious diseases noted above I have no means of determining, but 
I am disposed to think that probably from one-third to one-half of 
all cases arise in this way. 

While, therefore, we account for quite a large proportion of in- 
stances of hypertrophied tonsils by the predisposing influence of the 
lymphatic habit, and accept the occurrence of one of the exanthems 
as the immediately exciting cause, we must recognize the fact that 
the disease may develop insidiously, and without any apparent cause, 
being an essentially chronic affection from the onset. 

Hamonic reports a number of cases which appeared to be due 
entirely to syphilitic infection. These instances all occurred in 
young adult life and in the earlier stage of the specific infection, 
usually from two to six months after the primary lesion. Hamonic 
takes the ground that these hypertrophies are in the nature of sec- 
ondary adenopathies in which the lymphatic bodies which form the 
faucial tonsils assume the same relation to the syphilitic infection as 
do the lymphatics of the cervical and other regions. 

Pathology. — In an earlier work I described for the first time, I 
think, two varieties of hypertrophied tonsils, viz., the hypertrophic 
form and the hyperplastic form, the former term being used to desig- 
nate the variety of enlarged tonsils most frequently met with, namely 
an abnormal increase of all the normal elements which go to make 
up the organ ; while the latter term was used to designate that form 
of hypertrophy ordinarily met with at a later period than early child- 
hood, and composed very largely of connective tissue. 

In the hypertrophic form we find the organ greatly increased in 
size, and studded as in health with from seven to twelve regularly 
shaped openings which mark the orifices of its crypts. It is covered 
by mucous membrane, which passes down into and forms a lining to 
the enlarged crypts. Its epithelium is unaltered. Beneath this, 
however, we find the papillae flattened and more widely separated 
than normal, apparently as the result of the distention of the organ. 
Beneath the mucosa we find a submucous layer, notably augmented 
by the deposit of connective-tissue fibres. The crypts of the tonsil 
are increased in size, and usually will be found extending down to 
the base of the organ. They contain a certain amount of worn-out 
and degenerated epithelium and mucus, forming the ordinary cheesy 
matter which so frequently shows itself on the surface of the organ. 
The tissue lying between the crypts is made up mainly of lymphatic 



432 DISEASES OF THE FAUCES. 

bodies largely augmented in size, each lymphatic body being invested 
by an increased amount of connective tissue, while the spaces between 
these investing fibres are also filled in by bundles of the same 
material. 

In the hyperplastic form, the only change which we note is that 
while the body of the tonsil is augmented by an increase in num- 
ber and size of the lymphatic bodies, the process which involves 
these is somewhat limited, while the excessive morbid process ex- 
pends itself in the development of the connective tissue surrounding 
the lymphatic bodies. To such an extent does this proliferation go 
on that the tonsillar crypts are practically destroyed and obliterated. 
In this way there is formed a large mass, made up of bundles of con- 
nective tissue containing within their meshes a certain number of 
lymphatic bodies. The blood-vessels are also markedly encroached 
upon, and the vascular supply therefore is notably diminished. The 
investing mucous membrane presents no abnormal appearances. We 
thus find a rounded, somewhat smooth-surfaced organ, presenting 
slight depressions on its surface, marking the locality of pre-existing 
crypts. It is of a pale color and largely made up of connective tissue. 

In both forms of enlargement we find the lymphatic bodies in a 
state of true hypertrophy, and yet the process belongs essentially to 
the tonsils, in that we find no traces of the giant cell which character- 
izes a scrofulous enlargement of glands, as found elsewhere in the 
body. 

The hypertrophy takes various forms and in some instances, 
probably as the result of repeated attacks of acute inflammation, we 
find the face of the enlarged organ firmly attached to the inner side 
of one or both pillars of the fauces — a condition which should always 
be investigated before operative procedures are undertaken, as other- 
wise the success of the manipulation might be hampered. 

Recognizing the fact that the disease is dependent on a diathetic 
condition, we can easily uunderstand why, in most instances, hyper- 
trophied tonsils occur bilaterally. The hypertrophied tonsil con- 
taining a number of deep, irregular crypts or pockets, the natural 
result is that considerable masses of mucus and worn-out epithelial 
cells collect in these pockets, which are provided with no mechanism 
for emptying themselves. These collections undergo fatty and cheesy 
degeneration, as is evidenced by the periodical discharge of grayish- 
white, ill-smelling masses from one or the other of the crypts. 

This same lymphatic diathesis which predisposes to the develop- 
ment of enlarged faucial tonsils predisposes also, with equal activity 
probably, to the development of hypertrophy of the pharyngeal tonsil. 
Hence it is the rule, rather than the exception, in children certainly, 



HYPERTROPHY OF THE TONSILS. 433 

that when we meet with the disease in one region we also find it in 
the other. 

Symptomatology. — The symptoms to which the presence of en- 
larged tonsils gives rise are to an extent mechanical, hampering and 
interfering with the proper function of the parts. If the enlargement 
is moderate, they give rise to no special disturbance other than a 
liability to recurrent attacks of acute sore throat. 

The same also may be said of the hyperplastic, viz., the dense, 
fibrous form of tonsil hypertrophy. 

The large spongy mass of the true hypertrophied tonsil, however, 
with its ragged exterior and largely dilated crypts, may give rise to 
both local and general symptoms of marked character. 

The character of the voice is altered, and respiration may be 
slightly impeded by the mechanical encroachment of the tumors 
upon the fauces and oro-pharynx. Notable dyspnoea, however, does 
not occur. 

Deglutition is liable to be interfered with to an extent dependent 
upon the size of the growths. 

While the interference with respiration may not cause any con- 
scious symptoms of dyspnoea, yet it does cause the nightmare so fre- 
quently observed in children. This symptom I regard as peculiarly 
symptomatic of enlarged tonsils. It arises from the fact that, the 
entrance of air to the lungs being slightly impeded during sleep, 
there follows a slowly but surely increasing lack of proper oxygena- 
tion of the blood, resulting in an increase of the besoin de respirer, 
until it culminates in a sense of oppression or suffocation, under the 
influence of which the child awakes alarmed and terrified. 

Mouth-breathing, especially in young children, is apt to be the 
rule, and as the result the fauces become dry and an irritating cough 
occurs during the night. If these symptoms present during waking 
hours, it may be the result of the growths hanging down and imping- 
ing upon the epiglottis, or the cough may be of reflex character. 

How far impairment of hearing is due to the enlargement of the 
faucial tonsils is a question by no means easy to determine, for an 
enlarged pharyngeal tonsil is a far more prolific source of middle-ear 
disease than of disease of the faucial tonsil. The two diseases occur- 
ring so frequently in the same individual, therefore, render it difficult 
to determine wherein lies the source of an existing impairment of 
hearing. That, however, the faucial tonsil does exercise an influence 
in many cases is clearly shown by the fact that the hearing improves 
by the removal of these glands. It is often stated that the deafness is 
due to the pressure of the enlarged faucial glands upon the anterior 
lip of the pharyngeal orifice of the Eustachian tube. I do not believe 
28 



434 DISEASES OF THE FAUCES. 

this is a very active factor in the production of deafness. I am dis- 
posed to think that a more active factor lies in the interference with 
the proper functional activity of the faucial muscles which have to 
do with the renewal of air in the tympanic cavity, viz., the petro- 
salpingo-staphylinus or tensor palati muscle and the spheno-sal- 
pingo-staphylinus or levator palati. 

While we occasionally find children with enlarged tonsils who 
enjoy apparently perfect health, I think it is the rule that the pres- 
ence of these large bodies in the fauces gives rise to a more or less 
notable impairment of the general health. As contributing to this 
we must recognize the fact that the digestion and nutrition are no- 
tably interfered with by these enlarged glands, and that offensive 
masses of cheesy matter which accumulate in the tonsils are squeezed 
out and swept into the stomach in the act of deglutition and set up 
gastric disturbance. In addition to this, we must bear in mind that 
every breath of air which passes into the lungs passes over these 
receptacles of effete matter, and must be to an extent polluted, as 
proved by the sour and fetid character of the breath in a large pro- 
portion of the cases. 

No discussion of hypertrophied tonsils is complete without refer- 
ence to Dupuytren's famous case, in which hypertrophy of the tonsils 
was supposed to have given rise to the so-called pigeon-breast and 
other distressing conditions. Writers generally agree now that in 
this case the deformity and the enlarged tonsils were both dependent 
primarily upon the rachitic habit. That a case of enlarged tonsils 
ever gave rise to chest deformity can scarcely be accepted. 

Diagnosis. — Any enlargement of these organs is of course easily 
recognized upon direct inspection. In order, however, to properly 
estimate the character and extent of the hypertrophy it is a matter of 
some importance that the fauces should be inspected while at com- 
plete rest, for, as we know, if the parts are irritated, retching occurs, 
the first motion of which consists in the contraction of the palato- 
pharyngeal muscles. In this movement the tonsils are thrown for- 
ward to such an extent that even those which are but moderately 
enlarged will appear as if they were in contact in the median line. 
It is therefore necessary that the tongue should be pressed down 
firmly but slowly, while at the same time it is drawn forward, the 
spatula being placed well back upon the dorsum. 

As before stated, the enlarged organ may project prominently 
into the fauces, or it may lie deeply between the pillars in such a 
way as not to project beyond their border. It is important, then, 
that we should recognize the existence of a hypertrophic process, even 
though the enlargement has not attained large proportions, for, as we 



HYPERTROPHY OF THE TONSILS. 435 

have already learned, a very moderately enlarged tonsil, especially 
in an adult, may be the source of no little annoyance or even suffer- 
ing. We must bear in mind also that we not infrequently find that 
the surface of the tonsil has formed adhesions with the pillars of the 
fauces in such a manner as to cover up and mask the diseased struc- 
tures. The existence of these adhesions is easily elicited by the use 
of a bent probe. As a rule, they are not very firm, and are easily 
broken up. Thi^ should be done in all cases in order to accurately 
determine the extent of the morbid process. 

I have never met with a case in which the diagnosis presented 
any points of difficulty. Mistakes may occur, however. Malignant 
disease, for instance, may develop so insidiously as to fail of recogni- 
tion in its early stages. Thus Campbell reports a case in which, 
seven weeks before death from carcinoma of the tonsil, the organ 
presented no appearances which indicated other than simple hyper- 
trophy ; while a number of cases are reported as having been operated 
upon in Schroetter's clinic for simple enlargement, which were sub- 
sequently discovered to have been lympho-sarcoma. The only sug- 
gestion to be made here is that a unilateral enlargement of the tonsil, 
in adult life, should be looked upon with suspicion, and investigated 
with the utmost care, especially if the patient has passed middle life. 

Prognosis. — Hypertrophy of the tonsils may commence in foetal 
life, at any period of extra-uterine life up to the age of from twelve 
to fifteen, when the tendency to its development apparently ceases. 
I have never known a case of enlarged tonsils to develop after pu- 
berty, although there is no question that certain adventitious condi- 
tions may occasionally develop in these organs by which they become 
a source of irritation. 

While, therefore, the prognosis toward disappearance at puberty 
is fully recognized, and while, moreover, the disease itself entails no 
special danger to life, I think we must recognize the fact that it con- 
stitutes an exceedingly serious menace to health, not only in those 
symptoms which belong to the disease itself, but also, and this fact I 
think should be especially emphasized, because these large, spongy 
masses in the fauces of a child involve a particular susceptibility to 
the infectious diseases of childhood, especially diphtheria, scarlet 
fever, and croup. I think, therefore, that physicians are scarcely 
justified in waiting for the process of nature to remove these organs 
by atrophy, even if it be a matter of but few years until puberty 
comes on, for those few years may be a period of danger to the 
child. Moreover, I know of no possible objection against their extir- 
pation. I regard enlarged tonsils in the fauces as neoplasms, quite 
as much certainly as a fibroma or other homologous growth. 



436 DISEASES OE THE FAUCES. 

Treatment. — The prominent indication for treatment in this con- 
dition is the removal of the growth, and the main subject for discus- 
sion is as to the best means of accomplishing this end. Largely as 
a concession to the prejudice against cutting-operations on the part 
of parents, the attempt has been made to dissipate these tumors by 
means of absorbents, astringents, and caustics. 

We all recognize the almost specific action of preparations of 
iodine in producing absorption of lymphatic enlargments, but I think 
we must also recognize the fact that this action is limited to the 
earlier periods of hypertrophy. Hence, while acknowledging that 
something may be accomplished in the very early periods of life by 
its use, I question whether any practical reduction is accomplished 
by such application in the ordinary run of cases such as present for 
treatment. 

The usefulness of astringents, however, which are advocated 
much more extensively in medical literature, is in my mind open to 
serious question, and their action is limited simply to the reduction 
of the inflammatory process, exerting no influence whatever upon the 
hypertrophic condition. 

Perhaps the best of these local astringents is glycerole of tannin, 
applied daily by means of a camel' s-hair pencil; nitrate of silver 
(three to five grains to the ounce) ; sulphate of zinc, five to ten grains 
to the ounce ; sulphate of copper, three grains to the ounce ; or the 
insufflation of powdered alum are all in use. 

Curiously enough, we still find many authorities advocating the 
use of caustics for their destruction, such as chromic acid, nitric acid, 
nitrate of silver, chloride of zinc, Vienna paste, and the potential 
cautery. 

Chemical agents in destroying these glands must be used with a 
great deal of care, else neighboring tissues are in danger of being 
injured. It is at best an exceedingly slow and unsatisfactory process. 

In addition to the above, injections of tincture of iodine, carbolic 
acid, and chloride of zinc are recommended. These measures are, I 
think, open to the same objection as the chemical caustics already 
alluded to. 

Among potential cauteries are to be included the Paquelin cau- 
tery and the galvano-cautery. 

At the present day, one would scarcely think of using the actual 
cautery. Most observers unite in recommending that in using the 
galvano-cautery a slender-pointed electrode be chosen, and that a 
number of punctures be made with this instrument in the face of the 
hypertrophied organ, much better results being accomplished in this 
manner than by superficial burning. If it becomes necessary to re- 



HYPERTROPHY OF THE TONSILS 437 

sort to local destructive measures in the treatment of enlarged tonsils, 
this method undoubtedly is the one to which preference should be 
given. At the best, however, we must anticipate a somewhat pro- 
longed treatment. 

Tonsillotomy, I think, then, is the one measure of relief which 
should be advocated in all cases in which consent is obtained, unless 
some special reason exists contraindicating it. Excision of the ton- 
sil may be done by the bistoury, the cold-wire snare, the galvano- 
cautery ecraseur, or the tonsillotome. 

I see no reason why the use of the bistoury is a more thoroughly 
surgical procedure, as is stated, than the use of the tonsillotome. 
"Whatever measure accomplishes the desired end most successfully is 
the best surgery. Undoubtedly cases now and then occur, especially 
in adults, in which the tonsil is flat and deeply embedded between the 
two pillars in such a way that the tonsillotome does not reach it. In 
these cases the bistoury may be required, although in such cases my 
experience is very decidedly in favor of the cold-wire snare, and I 
very frequently resort to this instrument in the removal of small 
masses. The galvano-cautery ecraseur possesses the advantage of 
extirpating the tonsil without hemorrhage. It is a slow procedure, 
however, and one which will be found exceedingly difficult, especially 
in children, unless an anaesthetic be given. In an adult, however, 
there can be no question but that this device presents certain advan- 
tages, because I believe hemorrhage in an adult to be a danger always 
to be anticipated in removing tonsils, and one which occurs in quite 
a large proportion of cases. Potter makes the very excellent sugges- 
tion, that in removing tonsils by this method the loop should not be 
adjusted too deeply, because, in the process of burning through, a 
certain amount of tissue is destroyed beyond the cut surface, which 
subsequently comes away in the form of slough. 

After all that has been said in favor of the various devices already 
discussed, there is still no question in my mind that by far the best 
method of removing the tonsils, in the very large majority of cases, 
is by the tonsillotome. This consists practically of a ring-shaped 
knife, which is adjusted over the hypertrophied organ, and by a 
quick and simple mechanism enables the operator to remove the mass 
almost instantly. The advantage of this device is that the manipula- 
tion is practically unhampered by restlessness and struggling on the 
part of the child, the only requirement being that the mouth shall be 
kept open sufficiently long for the instrument to be adjusted over the 
tonsil. The operation is a comparatively simple one, and yet is one 
that requires a certain amount of manipulative skill. After an ope- 
rator, however, has acquired this skill, it is a very rare event to meet 



438 DISEASES OF THE FAUCES. 

with a patient whose tonsils cannot be successfully excised, in spite 
of struggling or resistance, and that too without resort to a general 
anaesthetic. 

To Physick is due the entire credit, I think, of having originated 
a device for the removal of these growths. Fahnenstock, Yelpeau, 
Gerson, and Maisonneuve all modified it, and Mathieu has further 
perfected the instrument, as is shown in Fig. 104. 

This instrument is not only exceedingly simple in its mechanism, 
but perfect in its action beyond axxy other device with which I am 
familiar. 

It leaves absolutely nothing to be desired in the way of a tonsil- 
lotome, on account of the ease and facility with which it is manipu- 




Fig. 104.— Mathieu's Tonsillotome, 

lated. Especially is it valuable on account of the shape of its distal 
extremity, in that the slender oval ring is inserted into the mouth 
and fitted around the tonsil more readily and more perfectly than by 
any other device. 

Mackenzie has modified the Physick instrument by attaching an 
adjustable handle to its proximal extremity, as seen in Fig. 105. In 
amputating a tonsil with this instrument, there is no device for secur- 
ing the mass after excision. This perhaps is not a serious objection, 
in that it is easily expelled after the operation; but the great objec- 
tion I find to Mackenzie's instrument is that the long diameter of the 
oval opening is antero-posterior, which is not the shape of the base 
of the hypertrophied gland. In the Mathieu instrument we have a 
small round ring attached to a slender shaft ; in the Mackenzie in- 
strument there is the broad blade, which renders it more bulky than 
the Mathieu instrument, and therefore of course less easily manipu- 
lated. Furthermore, an instrument held by the three fingers, as is 
the Mathieu tonsillotome, presents a far more convenient and easily 
manipulated device than one held in the full grasp of the hand. 



HYPERTROPHY OF THE TONSILS. 



439 



Any one, however, who is called upon to do this operation fre- 
quently, must necessarily be provided with at least three tonsillotomes 
of various sizes. For many years past all my work in this direction 
has been accomplished by four instruments, in which the oval open- 
ings measure as follows: f in. Xf in., j- in. X f in., 1 in. X $ in., 
and 14 in. X 1 in. 

In addition to this, we find in the instrument makers' stock a 




Fig. 105.— Mackenzie's Tonsillotome. 



large number of devices for the removal of the tonsils. Practically, 
however, I think the very large majority of those engaged in special 
throat work confine themselves to the use of either the Mackenzie or 
the Mathieu instrument. As before stated, my own preference is for 
the latter. 

In operating, the patient being in a sitting position, the tongue 
is easily depressed by a spatula in the left hand, while the tonsil- 
lotome, held in the right hand, is passed back into the fauces until 
its oval opening is directly opposite the tonsil, when it is carried 



440 



DISEASES OF THE FAUCES. 



down into the sulcus between the base of the tongue and the faucial 
arches, the plane of the opening being an angle of about 45°. After 
the lower segment of the opening has passed around the lower por- 
tion of the tonsil, the instrument is then swung upward and outward 
until the enlarged organ projects through the opening and the ring of 
the tonsillotome is seen to thoroughly encircle the tonsil at its base. 
After the tonsillotome is in place, it is, as a rule, I think, impossible 
for even young children to displace it by any involuntary movements 
of the fauces. Hence, while the movement already described should 
be accomplished as rapidly as possible, the further procedures can be 
done with a certain amount of deliberation, in order 
to secure the thorough extirpation of the diseased 
mass. After the instrument is in place, then, the 
spatula may be dropped from the left hand, and the 
shaft of the instrument should be grasped, in such 
a way as to press it firmly into 
place, while at the same time 
the shaft is quickly swung up 
and down through the arc of a 
small circle of which the tonsil 
is the centre, thus working the 
ring of the instrument well 
down to the base of the gland, 
when, by a quick contraction 
of the fingers of the right 
hand, the peculiar mechanism 
\ of the instrument is brought 
into play and the tonsil cut 
through. 

Fig. 106.— Method of using Mathieus Tonsillotome. As SOOn as this is accom- 

plished, the patient's head is 
brought well forward, so that the blood which follows the cut may 
make its escape through the mouth rather than into the fauces. 

The procedure described above is quite successful in the very 
large majority of instances, as after the introduction of the spatula 
the tongue is depressed, the mouth kept well open, and the move- 
ments of the head prevented by the firm grasp of the fingers of the 
left hand beneath the chin of the patient. 

Of course the above procedure is accomplished with the consent 
of the patient. With refractory children, I have always declined to 
use any force other than that described in the following plan of pro- 
cedure : the thumb, being enveloped in several folds of a thick towel, 
is inserted between the teeth of the child and forced backward be- 







HYPERTROPHY OF THE TONSILS. -ill 

tween tlie molars, thus holding the mouth well open, while at the 
same time the lower jaw is grasped firmly between the thumb and 
the first two fingers. In this way the movements of the head are 
perfectly controlled. The Mathieu tonsillotome is then used to de- 
press the tongue, while at the same time it is carried back into the 
fauces. When it is opposite the tonsil, it is passed down ^nto the 
sulcus between it and the base of the tongue, swung on to the mass, 
and the operation completed in the same manner as previously de- 
scribed. 

Passing the instrument over the lower portion of the tonsil is, I 
think, important, in view of the fact that in many instances the 
hypertrophied mass is to a certain extent pendulous, and presents a 
lower lobe, which hangs down, as it were, into the fauces below its 
attachment ; hence, if the instrument were put on from above down- 
ward, it would sever but a portion of the diseased tissue ; wdiile, 
applied in the manner described, the whole of the mass is embraced 
within the ring. 

A very large number of cases has come under my observation, in 
which the partial removal of the tonsils has given rise to but a limited 
amount of relief to symptoms. In my own work, I never feel thor- 
oughly satisfied in having done an operation of tonsillotomy unless, 
after the removal of the organ, I see the cut surface drop back be- 
tween the pillars of the fauces in such a way that these parts return 
to their normal i)osition, and practically no trace is left of the pre- 
existing diseased organ. Of course this is not accomplished in every 
case, but I think it is a result to be desired. 

In describing the operation, I have advised the crowding in of the 
tonsillotome upon the mass so as to engage as much tissue as possi- 
ble. For the same purpose it is well also to make use of external 
pressure. I do this on the ground that with the Mathieu instrument 
it is absolutely impossible to engage structures which should not be 
removed. Neither this instrument nor any other device is capable 
of thoroughly extirpating the tonsils in every instance. If, there- 
fore, any portions are found remaining after the use of the guillotine, 
I think they should be removed at the same sitting by means of the 
cold- wire snare. If both tonsils are diseased, as is the rule, I know 
of no reason why they should not both be extirpated at the same 
sitting. 

After the operation, if the organ has been thoroughly extirpated, 
in many instances relief follows almost immediately, and the patient 
is conscious of no further symptoms referable to his throat, although 
for perhaps an hour after the operation there is a bruised and sore 
feeling about the parts. In other cases, there is some slight exucla- 



442 DISEASES OF THE FAUCES. 

tion on the cut surface. A white membrane forms, there is more or 
less inflammatory trouble, with pain in swallowing, together with 
febrile disturbance. This condition lasts from four days to a week, 
and disappears spontaneously. If the symptoms are severe, it 
should be treated as an ordinary croupous tonsillitis. 

The ^operation is not especially painful, although rather terrifying 
to young children. I know of no objection, therefore, to removing 
tonsils without a general anaesthetic, provided one can gain sufficient 
control of the patient. It is better, moreover, that the patient should 
retain consciousness, and thus be enabled to expel the blood which 
flows after the operation. When a general anaesthetic is necessary, 
a few whiffs of chloroform should be given — just enough to produce 
slight and temporary unconsciousness. 

As soon as the tonsils are out, the child is laid prone on a sofa, 
with the head projecting over, and the blood allowed to drip into a 
bowl. 

If the patient fears pain cocaine may be brushed over the parts, 
but not injected into them. 

I believe the operation of tonsillotomy is practically one unat- 
tended with danger. 

As a rule, immediately following the removal of the organ there 
is rather free hemorrhage, which ceases, however, in the course of 
twenty or thirty seconds. In most instances, excessive hemorrhage 
comes on immediately after the operation ; in other cases there is a 
trifling flow at the time, the secondary hemorrhage occurring some 
hours later. 

In my own practice I have met with quite a number of cases of 
alarming and troublesome hemorrhage from tonsillotomy, all in 
adults. None of these, however, presents any points of special inter- 
est, with the exception of perhaps one. This was the case of a gen- 
tleman aged thirty -one. I removed an unusually large tonsil from 
the left side with the Mathieu guillotine, whereupon there followed a 
hemorrhage of so violent a character that any manipulation was ren- 
dered absolutely impossible. The blood poured from his throat in a 
stream. At the end of about three minutes syncope ensued, and the 
hemorrhage ceased instantly and did not recur. The amount of 
blood lost was from eighteen to twenty ounces. This patient was 
confined to his bed for a number of days, and did not fully recover 
his strength for several weeks. 

A large number of cases of hemorrhage after tonsillotomy which I 
have collated establishes a number of facts which heretofore have not 
been sufficiently accepted. The first and most important is that every 
one of these cases occurred in adult life. Indeed, I know of no re- 



HYPERTROPHY OF THE TONSILS. 443 

corded instance in which dangerous or even troublesome hemorrhage 
followed tonsillotomy in childhood, with the single exception of one 
reported by Capart, in which the tonsil was excised by means of the 
galvano-cautery loop, in a child eight years of age, and was followed 
by hemorrhage, which persisted for five days. The case is unique, 
and the question arises whether the source of hemorrhage may not 
have been in an injury to the faucial pillars, the persistence of the 
bleeding being the result of the constant movements of the paits. 

If the tonsil is one of any magnitude, its excision is an operation 
which is exceedingly liable to be followed by troublesome hemorrhage 
in probably the larger proportion of cases in adult life. Indeed, 
as the result of former experiences, I never undertake an operation 
in adult life without apprehension and without being prepared for 
emergencies. 

A second point which I think is fairly well established by the 
cases reported is that, while hemorrhage may be an exceedingly 
troublesome accident, it is not a complication which is dangerous to 
life, for, although we see somewhat vague references now and then 
in literature to death from this cause, I know of no case reported in 
sufficient detail to warrant its being accepted as such. 

I think also that experience shows very clearly the total ineffi- 
ciency of the ordinary remedies which are classified as styptics, 
haemostatics, etc. 

In quite a large proportion of cases the bleeding ceased spontane- 
ously. When the parts could be brought under easy inspection and 
the source of the hemorrhage traced to a spurting artery, it was suc- 
cessfully arrested by torsion. In the remaining cases the hemorrhage 
was arrested by pressure, with the exception of those in which the 
carotid was tied. 

Our first duty, therefore, is to examine the parts carefully, in 
order to detect, if possible, the source of hemorrhage. If this is 
found to be a spurting artery, this will usually be, I think, the ton- 
sillar artery, which, according to my experience, presents at the 
junction of the lower third with the upper two-thirds of the cut sur- 
face. When the source is found, an attempt should be made to arrest 
the bleeding by torsion. This measure failing, or the source of blood 
being in an oozing from the whole surface, two measures are open to 
us — the use of the actual cautery, or pressure. A simple method of 
pressure which is available in many cases consists in wrapping two 
or three folds of a light handkerchief about the thumb, and inserting 
it into the fauces, thus grasping and holding the bleeding surface be- 
tween the ball of the thumb in the inside and the forefinger applied 
behind the ramus of the jaw. The objection to this is that it may be 



444 DISEASES OF THE FAUCES. 

nceessary to maintain the pressure for several hours before the bleed- 
ing is arrested, which is somewhat of a tax to the endurance of the 
surgeon. As obviating this difficulty, Clendenin has devised an in- 
strument which accomplishes the same purpose. It consists of two 
long jointed arms, mounted with pads at their distal extremities, and 
so arranged that one pad can be adjusted to the bleeding surface, 
while the other is adjusted to the cervical region externally. It is 
fitted with a screw for regulating the pressure. Pressure by the 
thumb or by Clendenin's instrument is not always tolerated by the 
patient, on account of the retching which is excited. To overcome 
this a full dose of morphine may be administered hypodermically, or 
in an extreme case I see no objection to a few whiffs of chloroform. 




Fig. 107.— The Author's Snare for the Removal of Enlarged Tonsils. 

The above measures failing to arrest the bleeding, the next resort, 
I think, should be to the use of the actual cauterj, and the best effect 
is obtained from the use either of the heated irons or of the Paquelin 
cautery. The galvano-cautery electrode is so small that its heat is 
rapidly dissipated when applied to a profusely bleeding surface, and 
its haemostatic powers are thus impaired. The Paquelin cautery can 
be maintained at the proper haemostatic heat, viz., a dull red heat, 
and is not only easily regulated but affords an abundantly broad sur- 
face for burning the bleeding tissues. If the Paquelin instrument is 
not available, heated irons should be used . It is necessary that these 
should be of such size that the heat will not be rapidly dissipated 
by the flowing blood. 

As a final resort, ligature of the carotid artery may be successful, 
if demanded. 

While acknowledging the danger of tonsillotomy, I am of the opin- 
ion that troublesome hemorrhage can be avoided in the large ma- 



HYPERTROPHY OF THE TONSILS. 445 

jority of cases if not in all. Recognizing the fact that the operation 
in adult life is exceedingly liable to be followed by excessive hemor- 
rhages if cutting instruments are used, I have for a number of years 
confined myself to the exclusive use of the snare when a patient has 
passed the age of puberty. The instrument which I use is shown in 
Fig. 107. It is a modification of the ordinary polypus snare which 
goes under the author's name, but is of much stouter construction. 
Its mechanism is easily appreciated by a reference to the cut. The 
wire to be used is No. 10 steel piano wire. In many cases the opera- 
tion is finished without using the ecraseur. The instrument has 
worked admirably in all my cases, and in no single instance has the 
hemorrhage been more than of the most trivial character. 



CHAPTER LX. 

CROUPOUS TONSILLITIS, OR ACUTE FOLLICULAR 

TONSILLITIS. 

This affection is usually described as an acute follicular tonsillitis. 
In our discussion of inflammatory affections in the air passages, we 
have endeavored to establish a clear classification, in which the name 
of the disease should define, as far as possible, its pathological char- 
acter. In the disease under question, we consider that the local 
manifestation consists of a fibrinous exudation, or, in other words, 
a croupous inflammation involving the lining of the crypts of the 
tonsil. We adopt, therefore, the name of croupous tonsillitis in pre- 
ference to that of acute follicular tonsillitis, for the reason that, ac- 
cording to the classification adopted, the latter name properly would 
define a catarrhal inflammation. 

Most writers describe the affection as an acute follicular tonsillitis 
or amygdalitis, while a few use the term infectious tonsillitis. 

Etiology. — This disease was formerly regarded as a purely local 
affection. Latterly, however, I think all agree with the view taken 
in my earlier work, that it is a systemic disease or blood poison, 
characterized by a local manifestation in the fauces. In other words, 
we may, in a sense, regard it as one of the exanthemata, bearing a 
close relation to them in all its features, with the possible exception 
that it is not to be regarded as a contagious disease. This statement, 
of course, naturally involves the further assertion that it is to be 
classed as one of the germ diseases. My own view of its origin is 
that the germ, floating in the atmosphere, comes in contact with the 
ragged surface of the tonsil, and is entangled in the crypts, and from 
thence either makes its way into the circulation or, remaining local- 
ized at the seat of infection, gives rise there to those changes in the 
blood which create general febrile disturbances. At the same time 
a local inflammatory process of a peculiar character, viz., a croupous 
inflammation, is set up at the point of entrance. 

What the source of the germ is, of coarse, can only be a subject 
of speculation. Clinical observation, however, teaches us that it 
probably is some one of the various microbes attending the processes 



CROUPOUS TONSILLITIS. 447 

of decomposition in the conduits which carry off the waste matter of 
our houses, viz., the sewers. 

While undoubtedly in most instances the infecting germ makes 
its way into the air passages through the air, it is altogether prob- 
able that it may be conveyed in other ways. Thus, Cotterill has 
recorded an epidemic which broke out in a bojs' school. Its source 
was traced to milk from cows with diseased udders. That the con- 
tagion was carried in the milk seems to have been fairly well estab- 
lished, from the fact that the epidemic was arrested by boiling the 
milk. Carter lays a certain amount of emphasis on the atmospheric 
conditions as an active cause of the disease. As before stated, I re- 
gard croupous tonsillitis as a specific disease, and hold that it there- 
fore cannot be the direct result of an exposure to cold; taking cold, 
and its resultant inflammatory process, must be regarded as an active 
predisposing cause of the disease, and nothing more. 

In the same way, I think that an exceedingly important predis- 
posing factor lies in a diseased condition of the tonsils. 

It is usually considered as essentially a disease of childhood. The 
explanation of this is that the physical conditions of the fauces which 
actively predispose to the disease are met with in child life more often 
than at any other period, viz., an hypertrophied state of the tonsils. 
In addition to this, children are far more liable to attacks of catarrhal 
inflammation about the upper air passages, which also act as a pre- 
disposing cause of croupous inflammation. I think we must also ac- 
cept the fact that the resisting power of a child being less than that of 
an adult, he becomes an easier victim to the invasion of a disease 
germ. 

The question of the contagion of croupous tonsillitis is one which 
has been the subject of somewhat active discussion. It is by no 
means a difficult matter to establish the apparent fact that when the 
disease runs through a family, or through a neighborhood, one child 
has contracted it from another. These observations, however, as a 
rule, are deceptive. The disease usually manifests itself as an epi- 
demic, occurring in the fall and spring months, when colds are prev- 
alent and exposures frequent. It is far more liable, however, to run 
through a single family or a restricted locality than to spread through 
a large community. The largest prevalence which has been observed 
has been in institutions where a number of children are aggregated, 
such as schools or asylums. In most instances in which this has oc- 
curred the source has been traced to defective house sewerage. When 
it prevails in a community, this source is traced to unsanitary con- 
ditions involving the whole of the district affected. Therefore, while 
there is a possibility of contagion by absolute contact, I do not be- 



448 DISEASES OF THE FAUCES. 

lieve that, further than this, the disease is to be regarded as of a con- 
tagious character. 

I have frequently observed attacks of croupous tonsillitis in the 
mother or attendant of a child sick with diphtheria, and I believe 
there is a certain indirect connection between the diseases. This, 
however, will be discussed in another place. 

Pathology. — The essential morbid lesion which characterizes 
this disease consists of a croupous inflammation involving the lining 
of the crypts of the tonsil. These are to a certain extent distended 
by this deposit, which makes its appearance in the rounded, pearly 
white discs at their mouths. In connection with the croupous in- 
flammation, there is usually a considerable amount of catarrhal in- 
flammation involving the whole mass of the tonsil and extending 
somewhat to the mucous membranes of the faucial pillars and sur- 
rounding parts. 

A microscopic examination of the exudation reveals simply a 
large number of fine fibrinous fibrillae, crossed and interlaced in 
every direction, which embrace within their meshes leucocj'tes, epi- 
thelial cells, and certain extraneous matter. 

The search for a specific germ in this form of tonsillitis has been 
made by a number of investigators. Frankel discovered the existence 
of the staphylococcus pyogenes aureus and albus, while Gabbi has 
found the encapsulated bacillus of pneumonia. 

The membrane makes its appearance somewhat suddenly and 
persists from three to five days, and even longer, reproducing itself 
after removal with quite the same activity as in the primary de- 
posit. As a rule, it is a soft and friable exudation, breaking down 
easily, in which case it confines itself to the small circle immediately 
about the mouth of the crypt. In other instances it seems to be of a 
denser, more efflorescent character, and in this case its area of deposit 
is larger, speading to the tissue between the lacunae, forming a well- 
developed false membrane. 

There is no difference between the follicular disease and what was 
formerly called croupous tonsillitis, except in the degree of the in- 
flammatory activity. 

The original exudation confines itself somewhat closely to the ori- 
fices of the crypt, without extending very deeply into its cavity. 
Moreover, commencing as a croupous inflammation, it maintains its 
specific character during the whole continuance of the morbid process. 

Occasionally we find a suppurative process developing. This, 
however, is purely adventitious and bears no special relation to the 
croupous process. 

The disease being of an acute infectious character, we should 



CROUPOUS TONSILLITIS. 449 

naturally expect that the cervical glands would be involved and this 
as a matter of fact generally occurs. The disease usually involves 
both tonsils simultaneously, and this is always tru.e if the attack is a 
well-marked one. It is not essentially a disease of the tonsils, be- 
cause it is often found extending to the lymphatic tissues of the 
pharyngeal vault and oropharynx. 

Symptomatology. — The onset is marked by very decided chilly 
sensations. These are immediately folowed by a general febrile 
movement, characterized by headache, loss of appetite, pain in the 
bones, and general malaise. Pain in the back is also a prominent 
symptom. Then succeeds a feeling of uneasiness and dryness in the 
fauces, but the active eruption of the follicular disease is usually 
postponed from twelve to twenty-four hours after the onset of the 
systemic disturbance. When this apjpears, the local symptoms in 
the throat assume a considerable degree of prominence, pain being 
the pronounced feature. While this is not constant in all cases, 
there is a persistent sense of fullness and discomfort about the fauces, 
together with a sharp, lancinating pain with every effort of degluti- 
tion. 

The general febrile disturbance, at the onset of the disease, is 
marked by a temperature running from 102° to 104° F., and in young 
children is apt to be even greater; indeed, in very young subjects all 
the general symptoms are much more prominent, while the local 
symptoms are not so easily recognized. So great is this febrile dis- 
turbance in young patients that the commencement of the attack may 
even be marked by the occurrence of convulsive movements or well- 
marked eclampsia, the temperature running as high as 105° or 106°. 
In adult life, on the other hand, the temperature is usuallv from 100° F. 
to 102° F. 

The pulse is usually full, bounding, and running from 100 to 120, 
according to the age of the patient. 

These general symptoms continue for from twenty -four to forty- 
eight hours, when, as a rule, the febrile movement subsides to a no- 
table extent, and, the disease running its course in from five to seven 
days, the latter period is characterized by a somewhat moderate extent 
of fever. The painful local symptoms, however, as a rule, continue, 
unless ameliorated by treatment, until the disease undergoes resolu- 
tion. Occasionally there is a relapse on the fourth or fifth day. 

The occurrence of albuminuria is often regarded as diagnostic 
evidence of the diphtheritic character of the disease. I believe it to 
be entirely distinct from diphtheria, and yet albumin is not infre- 
quently found in the urine during the course of the attack, coming on 
usually earlv and disappearing with the defervescence. 
29 



450 DISEASES OF THE FAUCES. 

Further evidence of the infectious character of the disease is 
thought by some to be furnished by the occurrence of the albuminuria, 
due, it is claimed, to the passage of bacteria through the renal 
tubules. The existence of an enlarged spleen during the attack, in 
many cases, also tends to strengthen the theory that the disorder is 
infectious. 

Diagnosis. — Of course the interesting x>oint in this connection 
always is as to the possibility of the case being diphtheritic in char- 
acter, and a differential diagnosis can be established between the 
diseases only by the presence or absence of the Klebs-Loeffler bacillus. 
When brought under inspection, the tonsil is found red and swollen, 
while at the same time, at the mouths of the crypts of the tonsil, 
there will be found presenting small rounded spots or discs of a 
clear, bluish-white or pearly white color, smooth, and closely adher- 
ent to the mucous membrane beneath. These spots vary in size from 
a large pinhead to perhaps that of a split pea. If we take a small 
probe, with a thin pellet of cotton upon it, and attempt to remove 
the exudation, this will ordinarily be found easy of accomplishment. 
If the exudation simply fills and distends the orifice of the crypt, 
however, it cannot be removed without injury to the parts. 

Diphtheritic exudation frequently is seen in its early stages com- 
mencing at the orifices of the crypts of the tonsils. The graver form 
of disease presents a thicker, more efflorescent membrane, standing 
out prominently upon the mucous membrane. It is of a yellow color, 
and closely adherent to the parts beneath. The underlying mucous 
membrane is of a somewhat bluish or turgid hue, in contradistinction 
to the bright arterial red of the mucous membrane which underlies 
the croupous exudation. At the end of twenty -four to thirty-six 
hours, the diphtheritic membrane shows evidence of the local necrosis 
by the yellowish-black tinge which it takes on and the sanious dis- 
charge which pours from beneath it. The croup membrane, on the 
other hand, remains white and healthy-looking. 

Prognosis. — The disease runs its course in from four days to a 
week, and, while involving no special danger to life, it causes much 
discomfort and even suffering to the patient while the attack persists. 
There are certain complications, however, which, while adding per- 
haps no danger to the disease, increase the discomfort of the sufferer. 
Prominent among these is the occurrence of a suppurative tonsillitis 
or quinsy. This is an especial danger in those who have the quinsy 
or rheumatic habit. The mistake should not be made of supposing 
that a croupous tonsillitis may terminate in a peritonsillar abscess, 
for there is no direct connection between these two conditions. The lo- 
cal inflammatory process in the throat simply precipitates an attack of 



CROUPOUS TONSILLITIS. 451 

cellulitis in those who are subject to quinsy. The occurrence of small 
abscesses in the tonsil from the obstruction to the mouth of the crypts 
has already been refered to, and does not notably complicate matters. 

Albuminuria, when it occurs, is not to be regarded as a grave 
complication, and yet I think this is a feature of the disease which 
should be watched with a certain degree of care. 

We do not regard cardiac disease as one of the complications 
which may follow an attack of croupous tonsillitis. 

While paralysis of the palate is usually considered to be a com- 
plication of diphtheria, many cases have been reported in which it has 
followed croupous exudations. In these instances the disorder 
promptly disappeared under the administration of general tonics and 
strychnine. 

In addition to the paralysis of the palate, a notable muscular weak- 
ness in the lower extremities has been occasionally noticed. 

It is quite possible that a large element in the causation of these 
paralyses lies in the local inflammatory process, which, extending 
somewhat to the muscular tissue, produces a sodden condition, as it 
were, by which they easily become involved in a paresis. Unques- 
tionably, however, the general blood poison is the active and efficient 
cause of the paralysis, the local condition simply acting as a predis- 
posing factor. 

A point of great interest in this connection is whether a croupous 
laryngitis or true croup ever develops as a complication of croupous 
tonsillitis. In my own opinion, there is no question that this may 
occur, although the danger is a somewhat remote one when we con- 
sider the very great frequency with which we meet with the disease 
in the tonsils and the exceeding great rarity with which it is followed 
by a deposit in the larynx. This extension to the larynx occurs in 
young children only, the tendency to croupous inflammation in the 
larynx disappearing, as we know, with the increase of years. Fur- 
thermore, I think this tendency of a croupous tonsillitis to be followed 
by a laryngeal complication, is increased to a certain extent by the 
richness or extent of the tonsillar deposit: thus, in those rare in- 
stances in which the fibrinous exudation spreads over the surface of 
the tonsil, forming a continuous membrane, if occurring in young 
children we must recognize that a serious danger exists of the same 
membrane making its appearance in the larynx. This occurs by a 
secondary and independent deposit in the parts below. 

I know of no reason why a child convalescing from croupous ton- 
sillitis may not have diphtheria, and possibly be more subject to it 
than when in perfect health ; but that the one disease should terminate 
in the other is not to be regarded as among the probabilities. 



452 DISEASES OF THE FAUCES. 

Teeatment. — The disorder causes considerable suffering and a 
certain amount of danger, both of which can be largely eliminated 
by a proper course of treatment. 

If the bowels are constipated, a saline laxative should be admin- 
istered. If the febrile movement is high, this is best controlled by 
the administration of antipyrin, giving five-grain doses to an adult 
every half-hour until five doses have been administered. For a child 
the dose is proportionately smaller. In this way not only is the tem- 
perature reduced, but the headache, which is oftentimes of a some- 
what distressing character at the onset of the disease, is markedly 
relieved. If the fever or headache recur, this same drug may be 
again administered and in the same manner after an interval of three 
or four hours. In this way the prominent general symptoms will be 
notably relieved in the first twenty -four hours. 

If the symptoms recur after this treatment, they rarely possess 
anything like the intensity which characterized the onset of the attack. 

It may be necessary to repeat this treatment on the second day, 
but as a rule this will not be required. We then simply put the 
patient on the use of quinine in three-grain doses for an adult, given 
three times daily, until the attack is completely controlled. 

For the amelioration of the local symptoms it has been the practice 
to use nitrate of silver or some of the milder astringents applied 
locally by means of an atomizer or brush. We can, however, more 
successfully combat the spread of the exudation, control the local in- 
flammatory process, and relieve pain, by the use of the officinal tinc- 
ture of iron. It is to be administered as follows : 

1$ Tinct. ferri chloridi, 3 ij. 

Glycerini, . . ad § ij. 

M. 

To adults this is to be given in doses of half a teaspoonful every 
hour, and to a child in proportion. The mixture is not a disagree- 
able one to take, and the glycerin gives a consistency to it by which, 
when taken in the mouth and swallowed, it diffuses itself about the 
fauces, and in this manner acts as a local application. Of course the 
mixture is to be taken without dilution. We not only get the local 
action of the iron but also the systemic effect by which the special 
blood condition is controlled. 

As additional topical applications, either the officinal tincture or 
a solution of the perchloride or persulphate of iron may be used. A 
pledget of cotton, wrapped on a slender probe and dipped into the 
solution, is applied to the croupous deposits. While the destruction 
of the membrane is thus accomplished, I believe the relief of pain is 



CROUPOUS TONSILLITIS. 453 

best obtained by the iron-and-gl} 7 cerin mixture. Even after the attack 
subsides and the local conditions in the throat clear up, the patient 
is liable to bo left in a condition which requires a certain amount of 
building up. For this purpose it is best to administer some general 
tonic containing barks and iron with the addition of strychnine, for 
perhaps a fortnight longer. Should muscular paresis occur, the only 
further indication is for the increased administration of strychnine. 

The usefulness of chlorate of potassium is greatly overestimated. 
It makes an excellent cleansing wash in chronic catarrhal diseases, 
but I doubt if it has any effect on acute processes, of either a ca- 
tarrhal or an exudative character. 

Iodoform and collodion, and salicylic acid have been recom- 
mended as applications for disinfecting purposes. 

The administration of sixty grains of salol in divided doses has 
been advocated, but though this drug undoubtedly possesses a certain 
potency in the treatment of quinsy, I cannot understand how it should 
have any notable effect upon a croupous exudation, other than con- 
trolling febrile movement. This suggests to us, however, the impor- 
tance of recognizing the quinsy habit when present, and of commenc- 
ing the administration of the salicylates somewhat early in the course 
of the treatment. 

A number of observers attach a certain amount of importance to 
the administration of aconite, but I think that the cases are ver}* rare 
in which its administration is indicated. 

But one more question remains for discussion in this connection, 
and that is as to the necessity of isolating our cases. We have already 
taken the ground that the disease is epidemic and endemic, but prac- 
tically not contagious. If, therefore, the diagnosis is thoroughly 
well established and beyond question, I see no reason for isolating a 
patient suffering from this disease. If, however, there be any doubt 
in the mind of the medical attendant, the case should be isolated un- 
til the character of the exudation is determined by bacteriological 
examination to be non-diphtheritic. 



CHAPTER LXI. 

TONSILLITHS. 

Anatomically, an enlarged tonsil presents conditions more favor- 
able perhaps for the development of a calculus than any other region 
of the body. That it is Dot met with here, however, more fre- 
quently is probably due to the fact that the parts are subject to such 
constant motion and pressure, in the act of deglutition, that its 
formation is necessarily interfered with. In this region, as elsewhere, 
calcareous formation takes place around some foreign body acting as 
a nucleus. In the case of the tonsil, this is probably found in some 
particle of the cheesy matter which accumulates in the dilated crypts 
of the diseased organ. 

But one of these cases has come under my own observation. In 
this instance the patient was a man aged twenty -eight, from whom I 
removed from the left tonsil an oval mass, 1^ inches long, f of an 
inch wide, and \ an inch thick. This was embedded in the posterior 
portion of the left tonsil, and was easily removed by the index finger. 
The tonsil was notably enlarged, and the symptoms had been merely 
those due to the tonsillar hypertrophy. 

Etiology. — As before stated, I am disposed to regard a tonsillar 
calculus as due to the presence of a foreign body, although the exist- 
ence of a catarrhal inflammation, with the increased blood supply, 
may undoubtedly have its influence. 

It has been thought by some that tonsillar calculus is of parasitic 
origin. 

Robin finds a possible source of the calculi in minute calcareous 
crystals which the microscope shows to exist in the tonsillar glands. 
Schenck thinks they may be due to a gouty diathesis. No reports, 
so far as I know, however, have ever demonstrated the presence of 
urates. 

Pathology. — These calculi consist mainly of the phosphate and 
carbonate of lime, in somewhat varying proportions, together with a 
small quantity of carbonate of magnesium, water, albumin, and some 
organic elements. A foreign body is recognized as the nucleus. 

The calculus has its origin in the crypt of the tonsil, which be- 



TONSILLITHS. 455 

comes enormously dilated to accommodate the increasing proportions 
uf the deposit. In the case which occurred in my own practice the 
deposit was probably an unusually large one. In most of the cases 
the concretions are reported as of the size of a nut or an olive pit, 
and in some even smaller, but some have measured an inch in their 
longest diameter. 

Symptomatology. — Their presence gives rise to no prominent 
symptoms, other than those of an ordinary case of enlarged tonsils, 
and in most instances their presence is entirely unsuspected by the 
patient. 

There are repeated attacks of sore throat, the inflammation being 
of a catarrhal nature. Cough is a persistent symptom in some cases. 
Difficulty in swallowing is a symptom which is prominent, according 
to the size and location of the concretion. During the intervals 
between the attacks, the presence of the stone may not give rise to 
any especial annoyance. 

Diagnosis. — A tonsillar calculus is of whitish-gray color, dense 
in consistency, and, in a large proportion of instances, projects from 
the gland in such a way as to be easily recognized on the first inspec- 
tion of the fauces. In other instances it is completely embedded in 
the tissues in such a way that the tonsil presents no appearance 
whatever which would suggest the existence of a chalky concretion ; 
indeed, it has occasionally happened that the first knowledge of a 
calculus has been obtained in attempting the excision of the hyper- 
trophied gland, the knife or guillotine being arrested by the hard 
mass in such a way as to leave the operator in a somewhat awkward 
predicament. 

If a calculus is embedded in the tonsil and not recognized by 
ocular inspection, its presence is of course easily determined by 
palpation with the finger or an exploration of the crypt by means of 
a bent probe. 

Prognosis. — Chalky concretions in the tonsil probably possess no 
tendency whatever to spontaneous absorption or disappearance. 
Occasionally they become loosened in the act of coughing, and are 
expelled spontaneously. 

Their presence gives rise to no serious symptoms, and involves 
no special danger. 

Of course it is among the possibilities that one of these concre- 
tions should become detached and drop into the air passages below, 
although I know of no such accident having been reported. 

Treatment. — The only indication for treatment which they pre- 
sent is in their removal. This is ordinarily accomplished with ease. 
If the mass is in sight, it can be seized with a stout pair of forceps 



456 DISEASES OF THE FAUCES. 

and drawn from its bed. If the orifice of the crypt in which it is 
formed is smaller than the bulk of the mass, it is an exceedingly 
simple procedure to enlarge it by means of a bistoury. 

In my own case the mass was easily enucleated by means of the 
index finger inserted in the fauces. In a number of the cases re- 
ported, the stone was removed during an attack of acute inflamma- 
tion, which immediately subsided upon the removal of the calculus. 

After the mass has been extirpated, the further indications for 
treatment are the removal of the hypertrophied tonsil. This, I 
think, should in all cases be delayed until any acute inflammatory 
action which may have been present has disappeared. 



CHAPTER LXIL 

MYCOSIS OF THE FAUCES. 

This term is used as including those cases which in literature are 
described as mycosis tonsillaris, mycosis pharyngeus, etc. , according 
to that portion of the fauces wherein the disease has either its pri- 
mary origin or its most prolific development. 

It consists of a deposit upon the surface of the mucous membrane 
or within the crypts of its follicles, of the spores of mycosis lepto- 
thrix, which grows into vigorous plants, whose offshoots project 
noticeably above the surface of the membrane, while at the same 
time, by a more or less rapid progress, the area from which they* 
spring broadens until neighboring parts are involved. 

Etiology. — The immediate cause of the attack is the deposit of 
the specific spore upon some part of the mucous membrane. Its 
primary source, however, is somewhat problematical. 

Toeplitz, indeed, in his investigations, has isolated three differ- 
ent varieties of the leptothrix from the secretions in the mouth. The 
clinical status of the leptothrix is very clearly stated by Wagner as 
follows : " In every one it occurs upon the finely granular masses of 
decomposition within the teeth (summit of the papillae of the tongue, 
sediments around the teeth, tartar), in great masses in the thick 
brown coating on the tongue (typhus), constant in the intestines and 
in the faeces, very frequent in the vagina, sometimes in the lachrymal 
duct." The mouth, therefore, is probably the immediate source of 
the spores which give rise to the fungus development in the faucial 
mucous membrane. Why this transfer should take place it is not 
easy to state. 

That an acute inflammation of the membrane may favor its devel- 
opment seems to be quite reasonable — a fact which we frequently 
notice in connection with other disease germs. It is quite possible 
that an acid reaction of the oral secretions favors the more vigorous 
development of the spores. In six cases which have come under my 
own observation the patients were apparently in the best of health, 
with the exception perhaps of one case, that of a man of thirty, 
wdiose general health was somewhat impaired by overwork and ner- 
vous strain. 



458 DISEASES OF THE FAUCES. 

It usually occurs between twenty and thirty-five years of age, 
though no age is exempt. 

Pathology. — The leptothrix belongs to the schizomycetes group 
of fungi, its latter term applying to all those minute vegetable 
organisms which are almost ubiquitous in drains, refuse-heaps, run- 
ning streams, bogs, etc. They also appear in urine, milk, or other 
watery solutions containing organic matter on remaining exposed to 
the air for any length of time. The name leptothrix is given simply 
to that species of the schizomycetes in which the cells assume an 
elongated cylindrical or thread-like shape. When the spores of this 
plant lodge upon the mucous membrane of the fauces, these small 
thread-like bodies, augmenting rapidly by fission, multiply them- 
selves, gradually building up the plant-like mass of spores which is 
easily recognized on gross inspection, standing out from the surface 
of the mucous membrane as small, pointed, wartlike projections of a 
clear milk-white chalky color. 

When subjected to microscopic examination, it will be found that 
these masses are made up of a number of fully developed rod-like 
cells of leptothrix embedded in a mass of amorphous granules. 

If treated with a weak Lugol's solution, we find that the thread- 
like bodies assume a distinct bluish tinge, demonstrating the pres- 
ence of starch. 

When the disease penetrates into the crypts of the tonsil, the alter- 
ations in the organ appear to be confined almost entirely to the 
superficial epithelial layer, which is thickened, and the cells lose 
their characteristic form, probably from pressure, and become atro- 
phic and ill defined. The crypts become dilated and filled with 
the fungous growth and degenerated epithelial cells. The pres- 
ence of muscular fibres has been demonstrated in a mass of the 
vegetation removed from one of the faucial pillars, thus showing 
that tissues other than the lymphatic can be penetrated by this 
organism. 

Symptomatology. — The presence of this growth in the faucial 
mucous membrane seems to be tolerated with almost entire impunity, 
for it excites no inflammatory changes whatever in the membrane 
proper, the symptoms being of a purely mechanical character. As 
the plant increases in its area of distribution, the movements of the 
fauces become hampered somewhat, their flexibility lessened, and 
there is a feeling of stiffness in the region, especially during the act 
of deglutition, or in the other ordinary movements of the fauces. 
This is more marked, of course, in those instances in which the plant 
grows in the pharyngeal mucous membrane. Occasionally there is 
a slightly irritating cough. 



MYCOSIS OF THE FAUCES. 459 

It usually occurs in individuals in the enjoyment of perfect health, 
and its presence seems to give rise to no general disturbance. 

Diagnosis. — When the plant has attained such proportions and 
area of distribution as to be recognizable on ocular inspection, it 
makes its presence known in such a way as to be almost unmistak- 
able. It is usually found in its largest and most perfect development 
in the crypts of the tonsil, extending therefrom to the lateral walls 
of the pharynx, and to the glandular structures at the base of the 
tongue. Its starting-point most frequently is in the faucial tonsil. 
Next in frequency it has its origin at the base of the tongue in the 
lingual tonsil. Its occurrence or extension to the pharyngeal tonsil 
is somewhat rare, although it has been observed in this region. It 
has also been known to occur on the soft palate and uvula, and again 
to confine itself to the tongue. 

When seen, it presents in small, somewhat pointed masses or 
shoots, projecting from the surface of the mucous membrane, of an 
opaque, milky-white color, moist in appearance, and of soft consist- 
ency. 

There are few diseases with which it may be confounded, although 
possibly it might be mistaken for the cheesy masses which are so 
frequently found in the crypts of the tonsil. These latter, however, 
present an ordinary yellowish and somewhat fatty aspect, in distinc- 
tion to the clear, milky -white color of mycosis. Furthermore, the 
cheesy masses are easily pressed out of the tonsil, whereas the lepto- 
thrix can only be torn away with the rupture of blood-vessels. 

Acute follicular tonsillitis has something of the appearance of 
mycosis, and yet the evidence of local inflammatory action, together 
with the marked febrile disturbance which accompanies it, renders a 
mistake in diagnosis unnecessary. 

The disease generally starts on one side, but after persisting for 
some time it usually develops on the opposite side of the fauces. 

Mycosis cannot easily be confounded with diphtheria, as both the 
local appearances and the general systemic disturbance in diphtheria 
are so characteristic as to render such a mistake culpable, even in 
the early stages of either disease. Of course the microscope should 
in all cases render the diagnosis certain. 

Prognosis. — Mycosis seems to be a very harmless disease, and 
one which involves no dangerous tendencies. Having established 
itself in a favorable locality, it may apparently persist as long as life 
lasts. 

Treatment.— While we have intimated that the disease is purely 
a local one, and one which gives rise to no general disturbance, this 
does not militate in any way against the view that there are certain 



460 DISEASES OF THE FAUCES. 

systemic conditions which favor tne development of mycosis. Cer- 
tainly, when we consider the almost ubiquity of this germ, we are 
necessarily compelled to recognize some general condition which 
leads to its development in one individual, while so many others 
escape in whose oral secretions the leptothrix is undoubtedly present. 
The treatment, therefore, of the disease necessarily should be both 
local and general. Local measures consist of the eradication of the 
plant by such means as may tend to destroy the germs. There 
can be no question that the most favorable local condition for the 
development of the leptothrix lies in the spongy mass which 
makes up the tonsil. Hence the removal of this tissue very 
largely does away with the conditions favorable to its obtaining a 
foothold. This, I think, should undoubtedly be done in all cases 
when feasible. 

The local indications, then, consist in, as far as possible, remov- 
ing the tissue which favors its growth, while at the same time the 
plant itself is to be destroyed. Probably the galvano-cautery for 
destructive purposes, in its convenience of manipulation and in its 
efficiency, affords us a device which presents advantages over all 
others, although undoubtedly equally thorough work may be done 
with the milder destructives, such as chromic acid or the solid stick 
of nitrate of silver. I see no special good to be accomplished by the 
removal of the growth alone by means of forceps, without destroying 
the part from which it springs. In the cases which came under my 
own observation, the sharp curette was used, scraping away not only 
the mycotic growth but also the mucous membrane. This was fol- 
lowed by cauterization with chromic acid. The results were entirely 
satisfactory. In addition to the local destruction, the rubbing in of 
sublimate solution (1 to 2,000) will add to the probability of a suc- 
cessful result. 

Conceding that there is a systemic condition favoring the develop- 
ment of these growths, it becomes our duty to correct any general 
dyscrasia or habit that may be discovered in the individual, carrying 
out indications as they present. Special attention in this connection 
of course should be directed to the condition of the digestive appa- 
ratus, and any errors found should be regulated. As the lepto- 
thrix is supposed to flourish when the oral secretions are acid,, the 
free use of alkaline gargles seems to be indicated, as well as the 
internal use of alkalies. 

At best, the disease is an exceedingly obstinate one, and re- 
quires much patience and persistence, on the part of both the patient 
and the physician. The local destruction is to be accomplished 
with great care and minuteness of detail in thoroughly eradicating 



MYCOSIS OF THE FAUCES. 461 

every vestige of the disease, and even then, apparently, it is not al- 
ways possible to assure a patient that the cure is a radical one. Re- 
currence has taken place even as late as five years. This seems to 
emphasize still further the importance of general measures of treat- 
ment in connection with local applications. 



CHAPTER LXIII. 

HYPEKTEOPHY OF THE LINGUAL TONSIL. 

That hypertrophy of the lymphatic tissue in the glosso-epiglottic 
fossae might be the source of definite morbid symptoms was first sug- 
gested by Heymann in a somewhat casual reference to a case seen by 
him, and also a similar instance observed by Stoerk. 

Etiology. — We have already discussed in the chapters on the 
faucial and pharyngeal tonsils the general subject of the causation of 
hypertrophic changes in lymphatic tissue. Practically the same 
general rule applies to the lymphatic tissue at the base of the tongue. 
In this region, however, the follicles are displayed in a broad layer, 
involving the floor of the two glosso-epiglottic fossa?, and do not 
aggregate themselves into the thick masses such as are found between 
the faucial pillars. For this reason, perhaps, the hypertrophic 
changes do not result in the development of those large spongy 
masses which are found between the pillars of the fauces and in the 
vault of the pharynx. It is, moreover, a disease essentially of adult 
life, the symptoms rarely if ever manifesting themselves in children, 
the youngest case which I have seen being that of a young lady aged 
eighteen. 

Lymphatic changes, as we have seen, belong essentially to child 
life. Hence, we must conclude that, whereas the morbid process in 
the tissue commences in early life, the symptoms do not manifest 
themselves until later years. 

It occurs far more frequently in females than males, thus appar- 
ently reversing the rule which obtains with reference to the faucial 
tonsils. 

The starting-point of the trouble may lie in an attack of diph- 
theria, of scarlet fever, or in any of the acute infectious diseases. In 
most cases, however, it is probably a chronic process from the start, 
differing from other chronic inflammatory diseases in the fact that its 
course is not usually marked by recurrent attacks of acute inflamma- 
tion. 

Pathology. — As we have already learned, the meeting of the 
epiblast and the hypoblast at the isthmus of the fauces, in the devel- 



HYPERTROPHY OF THE LINGUAL TONSIL. 463 

opment of tlie foetus, is attended with a deposit of lymphatic tissue, 
which seems to form a girdle, as it were, in this region, encircling the 
isthmus ; the lymphatic tissue of the vault of the pharynx, or the 
pharyngeal tonsil, forming the upper portion of the girdle, the fau- 
cial tonsils forming its sides, while the circle is completed below by 
the similar structures found in the glosso-epiglottic fossae. The 
mucous membrane of the dorsum of the tongue is quite rich in mu- 
ciparous glands. In that portion, however, which extends from the 
papillae circumvallatse to the epiglottis they are so thickly distrib- 
uted as to form an almost continuous layer, although they vary 
considerably in different persons. Each individual gland is easily 
recognized, standing out somewhat prominently from the mucous 
membrane. In the centre of each projection, the minute orifice of 
the duct can often be seen with the naked eye. This duct opens into 
a wide flask-like cavity, lined with a prolongation of the mucous 
membrane from the orifice. Beneath this, we come upon a layer of 
large, rounded blind follicles or lymphatic bodies embedded in a 
delicate fibrous matrix, the whole gland being inclosed in a fibrous 
cajjsule. We thus find the pouch-like cavity of each muciparous 
gland completely invested by lymphatic tissue, constituting an indi- 
vidual secreting organ, in which the bulk is very largely made up of 
lymph tissue, and therefore one which is especially liable to become 
the seat of morbid changes. 

Symptomatology. — I am disposed to think that in most instances 
the annoying or distressing symptoms which this condition causes 
are present only when the hypertrophy is sufficient to more or less 
completely fill the glosso-epiglottic fossae and impinge upon the crest 
of the epiglottis. When this occurs, there is a sense of fulness in the 
throat, with tickling and irritation, under the influence of which the 
patient constantly endeavors to clear the throat. A dry, irritating, 
hacking cough is present in a majority of instances, attended with no 
expectoration, as a rule. Hoarseness or loss of voice, if such be pres- 
ent, is the result of independent causes, and not of an enlarged lin- 
gual tonsil, although the voice is weakened and tires easily. Indeed, 
the singing voice may be completely destroyed, without any apparent 
abnormal condition in the laryngeal cavity. A feeling of uncertainty, 
or lack of confidence in the voice, is especially noticeable with singers 
suffering from this condition. 

A patient is rarely able to nicely locate his symptoms, and yet 
occasionally he complains of the sensation of a foreign body impacted 
directly at the base of the tongue. In a few cases, the hypertrophy 
has attained such unusual proportions as to imprison the epiglottis. 

The whole train of symptoms is somewhat dependent upon the 



464 



DISEASES OF THE FAUCES. 



general habit, and is especially liable to be the source of annoyance 
in those patients in whom the nervous temperament is predominant. 
This, of course, explains the greater frequency with which the disease 
comes under our notice in females. As a rule, the symptoms are 
somewhat persistent and are notably aggravated with impairment of 
the general health, weariness, overwork, or any condition which taxes 
the nervous system. 

As a rule, I think we shall find that the most constant and char- 
acteristic symptoms of the condition are the irritation and tickling in 
the throat, with the persistent and annoying cough, while other man- 
ifestations are somewhat irregular and inconstant. 

Diagnosis. — It is not always an easy matter in any given case 
with symptoms referable to the throat to determine definitely where 

the source of the trouble lies. No 
examination of such a case is com- 
plete without an exploration of the 
whole of the upper air tract from 
the anterior nares to the trachea. 
Our knowledge of diseased condi- 
tions of the lymphatic tissue at the 
base of the tongue is of such recent 
date that it can scarcely be consid- 
ered superfluous to say that no ex- 
amination of the upper air tract is 
complete which does not take into 
account the possibility of an hy- 
pertrophied lingual tonsil as the 
cause of faucial irritation, a throat cough, or impairment of the 
voice. 

The examination is necessarily made by means of the laryngeal 
mirror, which will reveal the glosso-epiglottic fossae more or less 
completely filled with a mammillated, somewhat cone-shaped mass, 
of a pale pinkish color, and separated in the median line by a sulcus, 
which marks the site of the central ligament. The crest of the epi- 
glottis will be seen raised upon, and in some cases apparently 
embedded in, the apex of the hypertrophied mass (see Fig. 108). I 
think it is well to make the examination, not only with the tongue 
protruded, but with the tongue in situ, as in the latter position the 
amount of impingement upon the epiglottis is more clearly estimated. 
I know of no method of determining with absolute certainty that 
the lingual tonsil is the source of the symptoms, and yet I have fre- 
quently observed that, when the tongue is drawn forward in such a 
way as to separate the hypertrophied tissue from the crest of the 




Fig. 108.— Enlarged Lingual Tonsil as Seen 
in the Laryngoscopy Mirror. 



HYPERTROPHY OF THE LINGUAL TONSIL. 465 

epiglottis, a sense of relief from faucial irritation is experienced by 
the patient. 

A somewhat ingenious diagnostic is made by Seifert, who, after 
locating sensitive points, made an application of cocaine, producing 
anaesthesia, thus for the time giving entire relief to symptoms. 

Prognosis. — The condition is not a grave one, and involves no 
special danger to the general health, nor to the integrity of the air 
passages below. 

Treatment. — The indications for treatment are the same as 
in the faucial or pharyngeal tonsil, and consist in the ablation of the 
diseased tissue. In my own experience this cannot be accomplished 
by local applications, although undoubtedly marked temporary relief 
can be afforded by nitrate of silver, tincture of iodine, chromic acid, 
or any active astringent. The question arises, then, as to the best 
method of destruction or ablation. The galvano-cautery answers an 
efficient purpose undoubtedly in the smaller growths, but, when the 
mass is large, a number of applicatioDS will be required. My own 
experience with the galvano-cautery has been such as to lead me to 
abandon its use in these troubles. 

A serious objection to cutting instruments in this region lies in 
the fact that we not infrequently find a number of large veins distrib- 
uted about these growths, the cutting of which may result in trouble- 
some if not serious hemorrhage. I think, therefore, that we should 
resort to the potential or chemical caustic and cutting instruments 
with hesitation. I have found, in my own experience, that the cold- 
wire snare is not onh' more easily manipulated and more efficient 
than any of the devices above referred to, but that its use is attended 
with but trifling hemorrhage. The instrument that I prefer is the 
nasal polypus snare known under my name, the tube of which, being 
i)f flexible metal, can easily be bent to the proper curve, viz., to about 
the sixth of a circle. 

Before operating, a twenty-per-cent solution of cocaine should be 
applied, and, although this does not completely anesthetize, it no- 
tably diminishes the pain. This can be applied by the probe or by 
the laryngeal spray. 

In operating, the patient is directed to hold the tongue well pro- 
truded between the thumb and forefinger in the usual manner. The 
snare being held in the right hand, the loop is adjusted over as much 
of the growth as is feasible with the aid of the laryngeal mirror, held 
in the left hand, and the mass severed. This procedure is to be re- 
peated until the whole mass is extirpated. 

The removal of the growth, of course, is followed by a complete 
disappearance of symptoms, although the patient may have more or 
30 



466 DISEASES OF THE FAUCES. 

less pain for several days following. For the first day or two after 
the operation the food should be of bland and unirritating quality. 
A certain amount of relief can be afforded by directing the use of 
gum arabic, marshmallow, or the lactucarium lozenges sold in the 
drug stores under the name of the Pate Aubergier. This last, by the 
way, is an excellent remedy for the relief of the cough and throat 
irritation in those cases in which operative interference is declined. 
If the cough is severe, and does not yield readily to other remedies, 
a lozenge containing a small amount of codeine or opium may be ad- 
ministered. In this connection, mention should be made of the 
varicose condition of the veins at the base of the tongue, the symp- 
toms of which, to a certain extent, resemble the enlargement of the 
lingual tonsil. An examination with the laryngeal mirror easily 
reveals the large blue veins coursing through the tissues at the base 
of the tongue. The indication for treatment of this affection is in 
the use of the actual or chemical cautery. 



CHAPTER LXIV. 

DIPHTHERIA. 

Diphtheria is an acute infectious disease with constitutional and 
local symptoms, due to the influence of a specific germ, the Klebs- 
Loefner bacillus, which is found in great numbers in and about the 
characteristic pseudo-membrane covering the area of local inflam- 
mation. 

The Duality of Croup and Diphtheria.— One of the first prob- 
lems which presents itself for discussion is the question as to the re- 
lation which exists between croup and diphtheria. 

In a large proportion of cases of diphtheria, death results from 
suffocation due to the formation of a false membrane in the larynx or 
air passages below. Now, while the faucial exudation conforms an- 
atomically to Yirchow's original description of a diphtheritic mem- 
brane, the exudation in the larynx and trachea assumes more the 
form which he describes as croupous. On the other hand, cases are 
observed in which a croupous membrane forms in the larynx without 
any evidence of a diphtheritic process, and without the occurrence of 
a diphtheritic inflammation in the fauces. Those who advocate the 
duality of these diseases claim that the latter group of cases consti- 
tutes an entirely independent disease, viz., a croupous laryngitis, 
which bears no relation whatever to diphtheria. 

From a pathological point of view, it is certainly difficult to es- 
tablish the duality theory, basing our judgment entirely on Virchow's 
original teaching as to the differences between these two forms of 
inflammation, as they often merge into one another in such a way 
that it is impossible to establish any dividing line. At the present 
time, however, the diagnosis seems to depend upon the presence or 
absence of the specific germ of diphtheria. 

In the laryngeal complication of diphtheria, we find the membrane 
in the larynx permeated by the Klebs-Loeiner bacillus which is ab- 
sent in the ordinary form of laryngeal croup. In eighty per cent, 
however, of the cases of membranous croup reported to the Board of 
Health of the City of New York in 1894, the Loeffler bacillus was 
found by simply swabbing the posterior wall of the pharynx. 



468 DISEASES OF THE FAUCES. 

Aside from this pathological distinction there is practically no 
marked difference, either in the course or prognosis, between the two 
forms of the disease. 

It is perhaps not an easy matter to explain why in a case of diph- 
theria the inflammatory process in the fauces should be diphtheritic 
in character, while the morbid changes in the larynx and parts below 
should assume the croupous type, other than to suggest, perhaps, that 
the mucous membranes of the larynx and trachea, for some anatomi- 
cal reason, do not favor the development of a diphtheritic process. 
The fact, however, seems clearly established that the bacillus of diph- 
theria does set up two different pathological processes respectively in 
the fauces and in the parts below. So far as we understand these 
processes, however, it is a difference of degree rather than of character, 
the croupous deposit being practically a stage in the development of 
a diphtheritic inflammation. Again, we have this croupous mem- 
brane developing in the larynx, unattended by a diphtheritic process ; 
this would seem to establish the fact that croupous laryngitis exists 
as a disease distinct from true diphtheria, both from a pathological 
and from a clinical point of view. 

Etiology. — An attack of diphtheria is undoubtedly the direct 
result of the lodgement upon the mucous membrane of the specific 
bacillus, or the Klebs-Loeffler bacillus, where, finding a favorable 
nidus for its development and propagation, it sets up an inflamma- 
tory process at the point of arrest, which assumes the diphtheritic 
type. Pathologists unite in the view that this microbe does not make 
its way into the circulation. The systemic infection, therefore, is 
necessarily accounted for by the theory that the pathological process 
in the mucous membrane of the fauces gives rise to a toxin, and that 
the constitutional symptoms of the disease are due to the presence of 
this product in the blood. 

Predisposing Causes. — The disease is essentially one of childhood, 
by far the largest number of cases occurring under the age of ten. 
Those influences which predispose to the development of catarrhal 
diseases have an undoubted effect upon the prevalence of diphtheria, 
for, while it prevails in all climates and in all seasons of the year, it 
is far more frequently observed in the colder portion of the temperate 
regions, its frequency diminishing as we approach a tropical climate. 
Moreover, a larger number of cases are met with during the damp 
and cold months of spring and fall. A mucous membrane in a state 
of active acute inflammation affords a far more favorable lodgement 
for the development and propagation of a disease germ than does the 
same membrane in a state of health. A very important factor of the 
increased prevalence of diphtheria during the damp and cold months 



DIPHTHERIA. 469 

undoubtedly lies in the fact that our houses are much more tightly 
closed, and infectious germs are retained in the sleeping and living 
rooms of children. In the same manner defective hygienic surround- 
ings or conditions which weaken or impair the general health and 
lessen the resisting power of the system undoubtedly predispose 
somewhat to an attack of the disease. 

Perhaps a still more active predisposing cause than acute inflam- 
mation is the existence of enlarged faucial tonsils, and, in a less de- 
gree, enlarged pharyngeal tonsils. The danger to which a child with 
enlarged faucial glands is subjected cannot be overestimated, in that 
these large ragged masses of lymphatic tissue lying in the fauces 
afford a most favorable site for the lodgement of disease germs, which 
make their primary entrance into the system in the current of 
inspired air. 

Methods of Dissemination. — Diphtheria occurs endemically, epi- 
demically, and sporadically. The primary origin of the germ causing 
this disease is a matter of speculation. The localities favorable for 
its generation, however, are cesspools, privy vaults, and the sewers 
of great cities, and all places which are permeated by a foul atmos- 
phere, dampness, and especially such as are shut off from sun- 
light. 

We find diphtheria prevailing in epidemic form and with great 
virulence in rural districts and those far removed from the elaborate 
sewerage systems of large cities. In these instances the origin of 
the infection may be found in some local causes, such as neglected 
privy vaults or cesspools, or it may be conveyed over long distances 
from larger communities in which a more favorable condition for its 
development exists. 

It is a well-recognized fact that stagnant filth or decaying animal 
or vegetable matter in any locality may be the origin of the contagion. 
The germ having been in this manner primarily developed, however, 
it assumes such a form and possesses such a persistent vitality that 
it may be transported through long distances, by railways or other 
methods of land transportation, in baggage, in clothing, in letters, or 
may be carried by the current of air in the prevailing winds. It 
must be borne in mind, however, that in this wide dissemination the 
chances of its reaching a favorable nidus are immensely diminished. 
That the germ may be conveyed in drinking-water without impair- 
ment of vitality is clearly shown by reported cases. In the same 
manner the occurrence of cases of diphtheria in a large number of 
families obtaining their milk from the same vender shows clearly that 
the germ may be transmitted in this way. 

Cows, dogs, pigs, cats, sheep, pigeons, chickens, and other of the 



470 DISEASES OF THE FAUCES. 

lower animals are not infrequently attacked by diphtheria, and hence 
may be a source of contagion. 

An additional and most important source of the disease is found 
in individuals suffering from it. The throat of a child suffering from 
diphtheria becomes for the time a very prolific culture ground for the 
propagation of the specific germ which is the cause of the disease. 
The principal means b,y which the virus leaves the patient is the dis- 
charges from the nose and throat, the germs in this way escaping into 
the atmosphere or becoming entangled in articles of clothing, bed- 
ding, and furniture. Moreover, the danger of spreading contagion 
persists after convalescence has begun, as cultures often demonstrate 
the presence of the Klebs-Loeffler bacillus in the throats of the 
patients after all other evidence of the disease has disappeared. 

Pathology. — The bacillus. 

Since 1868, when Buhl first announced the bacterial origin of 
diphtheria, all observers have confirmed this view. It remained for 
Klebs in 1883 to definitely isolate the specific germ, and for Loeffler 
in 1884 to confirm Klebs' observation by culture experiments, thus 
demonstrating that the disease is due to the active presence of the 
micro-organism now generally designated as the Klebs-Loeffler 
bacillus. 

The bacilli occur singly, in pairs, and occasionally in chains of 
three or four. The germ is about the same length as the tubercle 
bacillus and twice as thick. The rods are straight or slightly curved, 
and may have club-shaped ends, or they may be pointed at the ends 
and swollen in the middle portion. They differ greatly in their size 
and shape, even in the same culture. Streptococci and other cocci 
are usually found associated with the micro-organism of diphtheria. 

Koux and Yersin isolated the toxin of the Klebs-Loeffler bacillus 
in 1888-89, and showed that this product was capable of giving rise 
to lesions identical with those resulting from injections of pure cul- 
tures of the bacillus itself. 

The Diphtheritic Process in the Fauces. — I am disposed to regard 
diphtheria as primarily a local disease. The specific germ, lodging 
upon the mucous membrane, reproduces itself more or less rapidly 
and penetrates the epithelium, setting up an active inflammatory 
process in the membrane, characterized by dilatation of blood-vessels, 
transudation of serum, and the escape of leucocytes. There is active 
proliferation of epithelial cells coincident with the escape of fibrin, 
which latter upon exposure to the air undergoes coagulation, forming 
a false membrane. The fibrin as it coagulates engages in its meshes 
large numbers of the newly developed epithelial cells and of the 
specific micro-organisms. As the direct result of this excessive 



DIPHTHERIA. 471 

activity, together with the contraction of the fibrinous bands, tissue 
necrosis sets in; the vitality of the false membrane, as well as the 
larger portion of the mucous membrane proper, is destroyed by pres- 
sure ; the necrotic tissue accordingly separates itself from the parts 
beneath and is thrown off in the form of a slough, and a new false 
membrane takes its place, or resolution may occur. In the large 
majority of instances the deposit occurs primarily upon the tonsils, 
and subsequenth' the pseudo-membrane extends to the faucial arch 
and the soft palate, and backward to the pharynx. In rare instances 
it extends into the nasal cavitj' proper. The tendency, however, is 
to the larynx, trachea, and bronchi. 

Changes in the Viscera. — As a rule the chauges which are met with 
in the visceral organs are such as may occur in any of the continued 
fevers. The mucous membrane of the bronchial tubes usually shows 
notable hyperemia throughout its whole extent, while local extrava- 
sations are by no means uncommon. Among the complicating lesions 
are oedema and broncho-pneumonia. The heart cavities may contain 
coagula and the muscular structures show degenerative changes. The 
kidneys in most of the fatal cases are notably enlarged and show evi- 
dences of local extravasations, while the tubules are the seat of in- 
flammatory changes. The liver and spleen in a certain proportion of 
cases are engorged, while the latter organ may be soft and friable. 
In addition to the above visceral changes, minute extravasations are 
occasionally found in the meninges and superficial portions of the 
brain and spinal cord. 

Symptomatology. — The stage of incubation of the disease varies 
from two to eight days, according to the virulence of the contagion. 

Diphtheria may assume an exceedingly mild form, or be of an un- 
usually malignant type, according to the extent of the local inflam- 
matory process or the degree of blood poisoning that may exist. 
This may depend to a certain extent on the character of the prevailing 
epidemic. It is an observable fact that the severity of the disease is 
much lessened during the later period of the epidemic invasion. 

For convenience of consideration, we divide the forms that the 
disease may assume into three : the mild form, the typical form, and 
the malignant type. In addition to the above three classes, there is 
the pseudo or false diphtheria, a condition which often closely simu- 
lates the true form of the disease. They differ, however, in that the 
Klebs-Loeffler bacilli are absent in pseudo-diphtheria, this disorder 
apparently being characterized by the presence of streptococci and 
other cocci in the exudation. They differ also in the fact that the 
mortality in pseudo-diphtheria is very low. 

The Mild Form. — This variety of the disease is characterized by 



472 DISEASES OF THE FAUCES. 

the development of a typical diphtheritic membrane in the fauces, 
with a certain amount of febrile disturbance, indicating the presence 
of the toxin in the circulation, and yet the membrane shows no 
disposition to extend beyond the tonsils, and the cases usually 
recover. 

The first symptom consists of chilly sensations, followed by gen- 
eral febrile disturbance, the thermometer showing an axillary temper- 
ature of from 100° to 101° F. The skin is flushed, pulse quickened; 
there are loss of appetite, pains in the bones, and the other indications 
of febrile movement. This is followed soon by a sense of uneasiness 
and stiffness about the throat with external tenderness, due to the 
enlargement of the cervical glands, together with pain in swallowing. 

During the first day there may be observed on the tonsils either a 
thin, bluish-white pellicle covering the whole surface or a number of 
small spots of the same color, which stand out somewhat above the 
surface of the mucous membrane, which is swollen and injected and 
presents the ordinary appearance of catarrhal inflammation, which 
involves the tonsils, the soft palate, and perhaps the wall of the lower 
pharynx. This hyperemia is of a somewhat darker color than that 
which characterizes an acute inflammation. If the exudative process 
is confined to one side of the throat, this hypersemic condition may 
also be unilateral. 

At the end of the first day or the beginning of the second, if the 
exudation has commenced in separate points on the surface of the 
tonsil, these will have extended so far as to completely cover this 
organ with a continuous membrane, which now takes on more of a 
yellowish aspect and becomes entirely opaque. Its surface presents 
a soft, velvety appearance, and it stands out more prominently from 
the parts beneath, showing notable thickness on inspection. 

In the course of the second or perhaps on the third day a muco- 
purulent secretion, moderate in amount, makes its appearance on the 
surface and about the edges of the false membrane, which now becomes 
somewhat raised, and shows a manifest disposition to separate itself 
from the parts beneath, presenting a ragged aspect. By the end of 
the third day, or even sooner, the membrane gradually turns to a 
bluish-brown color, indicating that the necrotic process has been 
completed, preparatory to the complete separation of the membrane 
from the parts beneath and its expulsion. This does not always 
occur en masse, as frequently it comes away in small particles or 
shreds, and gradually becomes thinner, until the reddened mucous 
surface is seen beneath. 

The febrile disturbance, which was characteristic of the first two 
days of the attack, subsides notably toward the end of the second or 



DIPHTHERIA. 473 

the beginning of tlie third day, and by the fourth or fifth day usually 
has almost completely disappeared. 

The whole course of an attack of this sort is usually completed in 
from ten to twelve days, the exudation disappearing and the parts 
beneath assuming a healthy aspect. If any forcible attempt is made 
to remove the .membrane at the onset, it may re-form prompt^, al- 
though if left entirely alone it shows but a limited disposition to re- 
produce itself after the natural process of exfoliation. 

The mild cases are quite as contagious as the graver varieties, and 
are often followed by the paretic and other sequelce. 

The Typical Form. — Under this head we describe that form of 
diphtheria in which the extension of the membrane into the larynx 
and trachea becomes the grave feature of the attack. 

The onset of the disease is marked by either chilly sensations or 
a well-developed chill. If there are prodromic symptoms, they con- 
sist simply in a feeling of general malaise, with restlessness and loss 
of appetite. In young children, vomiting and even convulsions not 
infrequently occur. The systemic invasion is shown by general 
febrile disturbance, flushed skin, headache, and pains in the bones, 
together with scanty and high-colored urine. The patient is apt to 
be dull, depressed, listless, and somewhat unobservant. 

The temperature is usually not much above 101° or 102° F. The 
pulse, while notably accelerated, is apt to be somewhat feeble and 
thready even at the onset of the disease. 

The throat symptoms develop almost coincidently with the febrile 
movement, the patient complaining of a sense of dryness and stiffness 
about the parts, with external tenderness and pain on swallowing, 
the lymphatics of the cervical region being invaded by the specific 
virus, usually within the first twenty -four hours. 

The exudation may commence as a thin pellicle, covering one or 
both tonsils, or it may commence in minute bluish-white spots, which 
at the end of a cornparati vely few hours have taken on a yellowish 
color. This discoloration may occur even before these points have 
spread so far as to produce a continuous exudation covering the 
organ. Within the first twenty-four hours the tonsillar membrane is 
completed, and presents a bright yellow, efflorescent, thick, velvety 
membrane, covering one or both tonsils and standing out prominently 
above the mucous membrane beneath. This is highly injected and 
swollen, and presents all the evidences of acute catarrhal inflamma- 
tion, except that the hyperemia is of the venous type, as evidenced 
by the dark-red color with a slightly bluish tinge. This discoloration 
extends somewhat to the soft palate, uvula, and pharynx. 

On the second day, or at the latest by the third, a muco-purulent 



474 DISEASES OF THE FAUCES. 

discharge sets in, and the membrane shows evidences of a necrotic 
process. The membrane also shows a disposition to extend itself, 
spreading up toward the soft palate and uvula, and also into the 
pharynx. If in the former direction the palate becomes swollen, 
while the uvula may become cedematous, being swollen to several 
times its normal contour. As the necrotic process develops in the 
exudation, the parts are constantly bathed with the muco-purulent 
discharge. This is dried up by the current of air in respiration, and 
thus adhering closely, forms an additional source of annoyance to the 
sufferer. The tongue, which at the onset is moist and slightly coated, 
now becomes dry and covered with a brownish, ill-looking fur. The 
breath becomes fetid, both from the local necrosis and from the re- 
tained secretions. The temperature by the third day generally goes 
down from one to two degrees. 

Up to the end of the third day, as a rule, the gravest symptoms 
which develop in the patient are those due to the blood-poisoning 
which results from the septic absorption, together with the interfer- 
ence with proper nutrition which the morbid process in the fauces 
entails. The most serious aspect which the disease presents at this 
time lies in the danger of the false membrane developing in the 
larynx. This usually occurs at the end of the second or during the 
third day. In rare instances it is postponed until the fifth. The 
occurrence of this complication is first shown by the hoarseness or 
complete loss of voice which results from it. This is soon followed 
by dyspnoea, characterized by obstruction both to inspiration and 
expiration, although of course, in the nature of the case, the expira- 
tory effort is accomplished with much more ease than inspiration. 
The development of dyspnoea is recognized by the ordinary symp- 
toms characteristic of laryngeal obstruction, such as subclavicular 
and abdominal depression, cyanosis, etc. The laryngeal stenosis is 
mainly the result of the false membrane, although undoubtedly a 
certain amount of paresis in the respiratory muscles of the larynx 
contributes no little to the symptoms. The occurrence of a deposit 
in the larynx is also evidenced by a recurrence of febrile movement. 

If life is prolonged for a sufficient time, the exudation may sepa- 
rate itself on the third or fourth day and be expelled, either in part 
or in a complete cast of the larynx and trachea. This is followed 
either by resolution or by reproduction of the membrane. If the 
faucial exudation is progressing favorably at the time the tracheal 
membrane is expelled, there is less probability of a re-formation in 
the parts below than if the diphtheritic process above is in a state of 
activity. Ordinarily, we may say that the development and exfolia- 
tion of a diphtheritic membrane is a process extending through from 



DIPHTHERIA. 4?5 

five to seven days, and the clinical history of an ordinary case of this 
form of diphtheria which progresses favorably, and in which suffoca- 
tion does not occur as the result of the tracheal exudation, covers a 
period of two weeks or longer. 

The Malignant Form. — We apply the term malignant to that form 
of diphtheria in which the prominent symptoms are dependent upon 
the profundity of the blood poison. The prodromic symptoms are 
usually absent. The onset of the attack is generally marked by a 
fully developed chill or notable chilly sensations. Vomiting not in- 
frequently occurs, and may persist for some time after it commences. 
Convulsions also are occasionally met with. The morbid process in 
the fauces differs in no marked degree from that of an ordinary attack 
of diphtheria. The febrile disturbance, which at first may be marked 
by a temperature of 101° or even 102°, usually disappears during the 
second day, and the further course of the disease is marked by a 
low temperature, or there may even be a total absence of febrile 
movement. 

The patient seems to be overcome at the onset of the disease by 
the exceeding virulence and activity of the morbid material which 
enters the circulation. This is evidenced by the peculiar bluish-gray 
aspect of the skin, the dull eye, the listless, apathetic condition of 
the patient, the failure to notice individuals or occurrences in the 
room. The pulse is rapid, feeble, and irregular; the urine is scanty 
and high colored, or it may be suppressed; the administration of 
food and drink is accomplished with considerable difficulty, not on 
account of any dysphagia or pain in deglutition, but rather from the 
general apathetic condition of the patient. The impression produced 
on the nerve centres by the toxins is evidenced in many instances by 
the occurrence of eclampsic symptoms or delirium, which is usually 
of the low, muttering type. Another nervous symptom of some im- 
port, and which is to be explained in the same way, is the absence of 
tendon reflex. 

If the patient survives to the third or fourth day, the local morbid 
process in the fauces may extend to the parts below and develop 
laryngeal stenosis; as a rule, however, a fatal issue ensues before the 
dyspnceic symptoms have developed sufficiently to contribute notably 
to the fatal termination. In other words, the disease seems to ex- 
pend itself in the development of the toxaemia rather than the forma- 
tion of membrane. 

Diagnosis. — A diphtheritic membrane primarily makes its appear- 
ance, in the very large majority of cases, on the face of the faucial 
tonsils. In rarer instances it begins on the pharyngeal tonsil. 
When the membrane commences in the naso-pharynx it very soon 



476 DISEASES OF THE FAUCES. 

extends to the level of or below the soft palate, in such as a way as 
to bring it into direct view. 

In the differential diagnosis between croupous and diphtheritic 
inflammation, emphasis is laid on the following points : A croupous 
membrane is thin, of a bluish-white color, with a shining, glazed 
surface, and is separable from the parts beneath; a diphtheritic 
membrane is thick, of a yellowish color, soft and velvety surface, 
and is closely adherent to the parts beneath. 

After the second day of a diphtheritic process, when tissue necrosis 
occurs, it assumes a bluish-black aspect, with ragged edges, and is 
attended with a more or less profuse muco-purulent secretion. The 
necrotic process, furthermore, is evidenced by the characteristic fetor. 
A croupous membrane remains croupous until the end, when it is 
exfoliated, either in a mass or in small particles. It is cleanly in 
aspect, healthy in color, and never attended with a muco-purulent 
secretion. On rare occasions we may meet with instances of fibrinous 
exudation which possess the characteristics of both processes or 
membranes which are on the dividing line between croup and diph- 
theria. 

Something, perhaps, can be learned from the tendency of the 
membrane to spread throughout the fauces. In a follicular tonsillitis 
the exudation confines itself, as a rule, to the mouths of the crypts. 
Occasionally it spreads over the tonsil, still retaining its croupous 
character. In the milder form of diphtheria we meet with cases in 
which the original deposit is limited to the face of the tonsil ; in these 
instances, however, the exudation presents the typical character of 
the diphtheritic process above described. Any membrane which, 
commencing on the tonsils, extends to the soft palate and uvula, is 
probably of a diphtheritic character. 

In pseudo-diphtheria, however, the membrane and general symp- 
toms often resemble the condition found in true diphtheria to such a 
degree that it is impossible to give a definite diagnosis without the 
aid of the bacteriologist. According to our present knowledge, the 
absence or presence of the Klebs-Loefner bacillus will decide the 
diagnosis in all doubtful cases. 

It has been claimed that the disease may occur primarily in the 
larynx or the nose, and subsequently extend to the fauces. I believe 
that the lymphatic tissue of the faucial and pharyngeal tonsils pre- 
sents the most favorable nidus for the lodgement of the diphtheritic 
germ ; and I regard this rule as so universal that I am disposed to 
think the primary origin in all cases of diphtheria is to be traced to 
the occurrence of a deposit on one of these three lymphoid masses. 

Prognosis. — Certain complications or sequelce which may precipi- 



DIPHTHERIA. 477 

tate a fatal issue, are common to both the mild and severe cases of 
diphtheria. As a rule, however, they are more apt to occur in the 
graver variety of the disease. The most prominent of these are refer- 
able to the heart, kidneys, and lungs, and are probably due to the 
more or less profound toxaemia which exists in diphtheria. 

The cardiac disturbance may consist of a rapid, feeble pulse 
throughout and after the attack, or a pulse which becomes progress- 
ively feebler and slower until it may reach as low as forty or thirty 
beats a minute, or there may be a sudden failure of the heart, which 
may occur either during the attack or during resolution. 

Albuminuria, present in a majority of cases of the disease, may in 
rare instances constitute a grave complication. As a rule, however, 
the renal changes are but temporary in character and rarely of seri- 
ous import. 

Bronchitis and pneumonia are complications which prove fatal in 
a large number of cases. 

In laryngo-tracheal diphtheria, while a notable extent of blood- 
poisoning is shown by the constitutional symptoms which develop, 
the tendency to death is in the main due to the development of the 
membrane in the larynx, with its resultant asphyxia. Woronichin, 
in an analysis of 445 cases of diphtheria observed in the Elizabeth 
Hospital for Children at St. Petersburg, during a period of nineteen 
years, shows that 63 had laryngo-tracheal diphtheria, while 103 were 
affected with the malignant type. Of those affected by the laryngo- 
tracheal form 55 died, the death-rate being 88 per cent. In these 
cases it is seen that the laryngo-tracheal form of the disease occurred 
in about 15 per cent. 

This differs notably from the statistics of Lunin, who, in a total of 
296 cases observed, met with 95 instances of laryngeal invasion, or 
something over 32 per cent. The total death rate in Woronichin' s 
cases was 55 per cent. In Lunin' s it was about 56. That this is not 
an excessive hospital mortality is shown by the fact that of 606 cases 
of the disease treated in the Hopital Trousseau in Paris for 1883, 
391 died, a death-rate of 64.5 per cent, while of 319 cases treated in 
the Charite at Berlin in 1885, 208 died, a death-rate of 65.5 per cent. 
The striking difference between the fatality of the disease as occurring 
in hospitals and at home is shown by the returns of the New York 
Board of Health. For eight years, extending from 1880 to 1887, the 
death-rate was but 42.62 per cent. The highest death rate, occurring 
in 1884, was 49.47, while the lowest was in 1883, being 34.37. In 
Boston during the same period the death rate in each year varied 
from 26.44 to 35.07, the average being 30.88 per cent, the lessened 
mortality there being undoubtedly due to the fact that the poorer 



478 DISEASES OF THE FAUCES. 

classes are not crowded together in large tenement houses to anything 
like the extent that prevails in New York. 

The prognosis in the malignant form of the disease is very grave. 
Thus, in Woronichin's cases it was 92.50 per cent, while in Lunin's 
it was 84 per cent. 

The larynx is often invaded in the malignant form of the disease ; 
but most frequently the septic infection is of such a violent type that 
the patient is overwhelmed by it at the onset of the disease, and suc- 
cumbs before the laryngeal invasion has developed to a sufficient 
extent to produce suffocative symptoms. Age is always to be re- 
garded as an excedingly important factor in forming a prognosis. In 
Woronichin's cases, the general mortality being 55 per cent, below 
the age of four it was 68.6; below the age of eight, 51.8; and above 
the age of 8, but 20 per cent. 

Since the introduction of antitoxin, however, the consensus of 
opinion is strongly in favor of the view that the rate of mortality in 
diphtheria has been more or less reduced. Though statistics are not 
always to be relied upon on account of the many and variable con- 
ditions upon which they depend, nevertheless, the difference in the 
rate of mortaility before and during the employment of antitoxin 
seems so marked that we are convinced of the efficacy of the remedy. 

Welch has collected the reports of 7,166 cases of diphtheria treated 
with antitoxin, the bulk of which came from children's hospitals. Of 
these only 17.3 per cent died. In 46 of the reports in his table the 
percentage of deaths from diphtheria previous to the employment of 
antitoxin is given for the same hospital or locality in which the serum 
treatment was afterward adopted. The number of cases treated with 
the serum amounted to 5,406 with 1,008 deaths, or 18.6 percent. If, 
however, the number of deaths were calculated according to the per- 
centages of the previous mortality given in the table, there would have 
been 2,279 deaths or 42.1 per cent. According to these estimates, 
therefore, there was an apparent reduction in the number of deaths 
of 55.8 per cent from the use of antitoxin. During the same period 
in which Koux treated with the serum 300 cases in the Hopital des 
Enfants Malades with a fatality of 26 per cent, the fatality in the 
Hopital Trousseau, also in Paris and receiving a similar class of 
cases, was 60 per cent, antitoxin not being employed at the latter 
place. Baginsky claims that, in unselected cases, he treated 525 
cases of diphtheria with antitoxin with a fatality of 15.6 per cent. 
During a period of forced interruption of this treatment on account 
of failure in the supply of the serum, 126 children were treated with- 
out antitoxin with a fatality of 48.4 per cent. Welch has also col- 
lected the reports, chiefly from hospitals, of 640 tracheotomies with a 



DIPHTHERIA. 479 

fatality of 39.8 per cent, 342 cases of intubation with a fatality of 
28.9 per cent, and 26 intubations followed by tracheotomy with a 
fatality of 53.8 per cent. All these cases were treated with antitoxin. 
If, however, the same mortality had followed the administration of 
the serum in these cases as had occurred previous to its use, accord- 
ing to the reports of most of the same hospitals and localities, the 
percentage of deaths would have been 64.5 per cent after trache- 
otomy, and 62.5 per cent after intubation. 

At the eighth annual meeting of the American Pediatric Society, 
held May 26, 1896, a report was given of a collective investigation 
into the use of antitoxin, which is especially valuable because it is 
confined to the results of treatment obtained outside of hospitals. 
The report includes 3^384 cases collected from the records of 613 
physicians. It also includes 942 cases from the reports of the 
New York Health Board, and 1,468 cases from the Chicago Health 
Board. 

The grand total gives 5,794 cases with 713 deaths, or a mortality 
of 12.3 per cent, including 218 cases which were moribund at the 
time of injection or died within twenty-four hours of the first injection. 

In the 4,120 cases injected during the first three days there were 
303 deaths, a mortality of 7.3 per cent, including every case returned. 
After three days have passed, however, before the injection, the 
mortality rises rapidly, and does not differ materially from ordinary 
diphtheria statistics. Yet improvement seems to have been noted 
in some cases even when the serum was injected as late as the fifth or 
sixth day. 

In the 3,384 cases reported to the society by private practitioners 
the larynx is stated to have been involved in 1,256 cases, or 37.5 per 
cent. In 691, or a little more than one-half the number, no operation 
was done, and in this group there were 128 deaths. In 563 cases, 
therefore, or 16.9 per cent of the whole number, there was clinical 
evidence that the larynx was involved, and yet recovery took place 
without operation. In many of these cases the symptoms of stenosis 
were severe, and yet disappeared after injection without intubation. 
A feature which excited much surprise was the prompt arrest, by the 
timely administration of the serum, of membrane which was rapidly 
spreading downward below the larynx. 

Operations were done in 565 cases, or 16.7 per cent of the entire 
number reported to the society. Intubation was performed 533 
times, with 138 deaths, or a mortality of 25.9 per cent. In 32 cases 
tracheotomy only was done, with 12 deaths, a mortality of 37.4 per 
cent. Of the 565 operative cases, 66 were either moribund at the 
time of operation, or died within twenty-four hours after injection. 



480 DISEASES OF THE FAUCES. 

In the 2,819 cases not operated upon, there were 312 deaths, a 
mortality of 11.3 per cent. 

Clinical experience seems, then, to have demonstrated the power 
of the antitoxin to check the extension of the diphtheritic process 
from the fauces to the larynx, and many observers have become con- 
vinced that fewer laryngeal obstructions occur after the administra- 
tion of the antitoxin, and that more patients recover from laryngeal 
diphtheria without the necessity of operation. 

In many cases of diphtheria, the prognosis is rendered more grave 
by complications and mixed infections due to other bacteria, which, 
when they are fully developed, do not submit to the influence of the 
diphtheria antitoxin. The most common and dangerous complicat- 
ing micro-organism is the streptococcus pyogenes. Streptococci and 
other cocci frequent healthy throats, and are usuall3 r found in the 
cultures from diphtheritic membranes. The pathogenic action of 
these germs, however, occurs only when they are present in very 
large numbers. In such cases they succeed not only in poisoning 
the system by the formation of toxins, but also in gaining access to 
the circulation and invading the liver, spleen, kidneys, and other 
organs-. 

Our prognosis is notably influenced by the character of the pre- 
vailing epidemic, the surroundings of the patient, the intelligence of 
the attendants, and such other circumstances as influence the course 
of any of the continued fevers. Moreover, it is to be borne in mind 
that cases which occur during an epidemic are more apt to assume 
the graver form than those which occur sporadically. It should be 
kept in mind that even a mild case of diphtheria is liable at any time 
to develop grave complications. 

The extension of the membrane into the nasal cavity is to be re- 
garded as a somewhat grave complication from the fact that the prop- 
agation of the germ occurs in a cavity which very soon becomes 
practically closed. In this way a condition is established which is 
especially favorable to the development of septic infection. This 
may be explained not only by the imprisonment of the germ, but by 
the great vascularity of the Schneiderian membrane. 

Treatment. — There are two important indications to be kept in 
mind in the management of any given case of diphtheria ; these are, 
first, to control and counteract as far as possible the constitutional 
effect of the toxaemia ; and, second, to limit the extension of the local 
inflammatory process and to destroy its infectious quality. This 
latter indication is emphasized by the fact that the propagation of the 
bacillus after it first commences in the fauces constitutes a continuous 
process, by which new ptomaines are rapidly manufactured, which 



DIPHTHERIA. 481 

make their way into the general circulation, adding to the original 
septic infection. 

Antitoxin. — To Behring belongs most of the credit of the discov- 
ery that the blood-serurn of animals which have be'en rendered im- 
mune against diphtheria by inoculation with pure cultures of the 
Loeffler bacillus contains an active principle which neutralizes the 
toxic agent existing in virulent cultures of the bacillus. Applying 
this fact, it was found that this blood serum from an immunized 
animal possessed a preventive and curative influence against the toxin 
of the diphtheria bacillus in the human body. In other words, in- 
jections of a suitable amount of the serum gave immunity to the per- 
son against the pathogenic action of the Loeffler bacillus, or neutral- 
ized the toxic product of that micro-organism when already present 
in the body. How this effect is produced it is as yet impossible to 
say, but the theory most generally favored is that it acts through the 
agency of the living body by rendering the cells tolerant of the toxin. 
It may happen that the cells are in such a condition that they will 
not respond properly to the action of the antitoxin. This may be due 
to intense or prolonged action of the diphtheria poison, to previous or 
coexistent disease, to inherent weakness, or to some individual idio- 
syncrasy. Usually, however, when administered sufficiently early 
and in proper amount, it arrests the spread of the local inflammation 
caused by the bacillus. Theoretically, it requires a given amount of 
the antitoxic agent to neutralize the effects of a given amount of the 
toxin. Practically, however, we have no way of determining the 
quantity and the virulence of the toxin, nor the susceptibility of the 
patient. In deciding upon the proper amount to give, therefore, we 
have to be guided by the duration of the disease up to the time of 
injecting the antitoxin, and the locality and severity of the disease. 
As a consequence, it will often happen that an insufficient quantity is 
given, and that the injection will have to be repeated. In laryngeal 
cases a large initial dose is necessary. All observers agree that cases 
coming under treatment the first day of the disease have much more 
prospect of recovery, and that they require less of the remedy. The 
fatality in some of the hospitals is about ten per cent in cases treated 
on the first day of the attack, runs up to about twenty -five per cent in 
those receiving the first dose on the second day, and reaches thirty- 
five per cent in the cases in which the antitoxin is not administered 
until the third day of the disease. In suspicious and in croup cases 
it is better, according to some authorities, to give the antitoxin at 
once, without waiting to determine by means of the bacteriological 
examination whether the Rlebs-Loeffler bacillus is or is not present. 
The failure of a case of diphtheria to respond to the timely injection 
31 



482 DISEASES OF THE FAUCES. 

of a proper dose of the serum is asserted by many to be an indication 
of streptococcus sepsis, broncho-pneumonia, or some other complica- 
tion due to secondary infection, over which the diphtheria antitoxin 
has no control.' 

While it appears from clinical records that the occurrence of albu- 
minuria, nephritis, heart failure, and paralyses is not increased by 
the antitoxin, as has been claimed by some, it is also seen that it has 
not been decreased, nor have these affections been influenced in any 
way by the administration of the serum. Kolisko, after having made 
one thousand autopsies of patients who had died of diphtheria, con- 
cludes that the anatomical changes in the internal organs are the 
same as under former methods of treatment. 

For a child over two years old, the dosage of antitoxin should be, 
in all laryngeal cases with stenosis, and in all severe cases, fifteen 
hundred to two thousand units for the first injection, to be repeated 
in from eighteen to twenty-four hours if there is no improvement ; a 
third dose may be given after a similar interval if necessary. For 
severe cases in children under two years, and for mild cases over that 
age, the initial dose should be one thousand units, to be repeated a« 
above if necessary ; a second dose is not usually required. Some of 
the disagreeable symptoms which occasionally follow the administra- 
tion of antitoxin have probably been due to the serum and not to the 
antitoxic substance. To prevent their occurrence, a diphtheria anti- 
toxin is prepared by some makers which contains a larger amount 
of antitoxin to each centimetre. Some point on the anterior surface 
of the chest or abdomen, on the back between the scapulae, or the 
outer surface of the thigh may be chosen for the injection. The 
syringe should be so constructed that it can be easily taken apart, 
and should be made entirely of material that can be thoroughly 
sterilized. 

Under influence of these injections in favorable cases, general 
improvement occurs in from twenty -four to forty-eight hours and is 
accompanied by a fall in temperature. In favorable cases the local 
diphtheritic process is arrested usually within twenty- four hours. 
The membranes separate rapidly in some cases, gradually in others. 
Swelling of the mucous membrane disappears, and convalescence 
rapidly ensues. The injection of the serum may be followed in a few 
hours by local pain, swelling, and redness, but there is no danger of 
abscess formation, if the serum is uncontaminated and proper anti- 
septic precautions have been taken. Unpleasant after-effects some- 
times occur. The most common of these is an exanthem, usually 
erythema and urticaria, which may be localized at the seat of injection 
or extend over the body. It is sometimes accompanied by fever. A 



DIPHTHERIA. 483 

severe form of the exanthem resembles erythema multiforme and is 
accompanied by high fever, pain in the bones and joints, and swell- 
ing of the joints. These conditions may seem serious, but the patient 
always recovers. 

In a number of children's hospitals and asylums, antitoxi 1 has 
been used for immunizing purposes. Some of the reports encourage 
the hope that the use of the diphtheria antitoxin will become more 
general, and that the prevalence of diphtheria will in this way be to 
a large extent limited. Many, however, consider it unjustifiable to 
use so powerful an agent for the purpose of prevention, as in some 
cases the serum has been known to cause untoward symptoms, and 
it is by no means certain that without its use the patients would have 
developed the disease. 

When it is desired to adopt this procedure, immunization is said 
to be effected by the administration of from one hundred and fifty to 
three hundred normal units of antitoxin, according to the age of the 
patient. The immunity ordinarily lasts about four weeks. 

Topical Applications to the Membrane in the Fauces. — Among the 
local remedies which possess special value in rendering inert a diph- 
theritic membrane, I should give the first place to some of the prepa- 
rations of iron, the order of preference perhaps being the officinal 
liquor ferri persulphatis and the liquor ferri perchloridi. If the 
membrane is thin and not especially efflorescent, the latter may be 
diluted with from one to four parts of alcohol. In applying this 
remedy, the patient should be placed in such a position that the 
parts are rendered easily accessible and are fully illuminated, when 
a slender probe wrapped with a small pledget of cotton is dipped in 
the solution and a small amount of the agent applied gently to the 
surface of the exudation. This is repeated until the whole of the 
membrane visible is thoroughly saturated with the iron. Moreover, 
the application should be made in such a way that the parts are in 
no degree injured and the application is confined entirely to the ex- 
udation. 

If seen early enough in the progress of the disease, and when the 
exudation is still confined to the tonsils, we may hope, even by the 
first application, to rob the local process of much of its infective 
potency and to limit its capacity for extension. The i^atient, however, 
should be seen a second time at least three or four hours later, when 
the same process can be repeated. Very much depends on careful 
watching, and frequent repetition of the visits during the first two or 
three days of the attack. 

The action of the iron is practically to antagonize and intercept 
the localized fibrinous process, thus rendering inert the nidus in 



484 DISEASES OF THE FAUCES. 

which the specific bacillus propagates. Its direct action upon the 
bacillus is probably somewhat limited. Next in efficiency to iron I 
should place the use of lactic acid as a local agent. This may be 
used in a fifty-per-cent solution, the strength being increased or 
decreased according to its effect. 

The bichloride of mercury has received extensive trial as a local 
application. I have no special knowledge of its efficacy when used in 
this way ; it certainly can have no effect on the inflammatory process, 
and cannot be expected to penetrate very deeply into the tissues for 
its action on the specific bacillus. 

Carbolic acid or phenol has been used more or less extensively as 
a local application, but ordinarily in such weak solutions as to ren- 
der it practically inert. 

Many other destructive agents have been recommended by differ- 
ent observers, but they have not proved so effectual as the above- 
mentioned remedies. 

Some years since pepsin, pancreatin, trypsin, and other digestive 
ferments were held in no little esteem as local applications to the 
membrane, the theory of their action being that they dissolved the 
exudation by a digestive process. I am disposed to think the effect 
of these remedies is very largely theoretical, and certainly should not 
feel justified in losing valuable time by trusting to their uncertain 
action. 

The peroxide of hydrogen has been warmly commended as a top- 
ical application, by means of the spray and by inhalation. 

Immediately upon the extension of the false membrane to the 
lining membrane of the nose, it becomes a matter of importance to 
arrest the process. The accomplishment of this requires careful 
watchfulness and somewhat deft manipulation. In order to gain 
freer access to the parts, the turbinated bodies should be exsangui- 
nated as far as possible by the application of a two-per-cent solution 
of cocaine, after which the secretions should be delicately removed 
by the use of a pledget of cotton upon a slender probe, and subse- 
quently a local application of the persulphate of iron should be made 
— the whole manipulation, of course, is carried out by means of the 
head-mirror with reflected light. This is to be repeated at intervals 
of from two to four hours, according to the progress of the exudation. 

A diphtheritic exudation in the nose assumes always a somewhat 
efflorescent type, the membrane being very thick and hence the pas- 
sages soon become more or less completely occluded. In such a 
case, of course, atomized fluid cannot be made to reach to any depth. 
The death rate in nasal diphtheria has been notably diminished since 
the systematic irrigation of the parts invaded has been the general 



DIPHTHERIA. 485 

practice, as in this manner the main danger of the disease, namely, 
septic infection, may be to an extent controlled. In this view a solu- 
tion of corrosive sublimate, one part in five thousand, becomes our 
main reliance. The best position in which the imtient can be placed 
for carrying out this manipulation is in the sitting posture, with the 
head bent well forward. If the heart's action is especially feeble, we 
simply turn the child's head well over upon the edge of the pillow, 
in such a way that the face hangs downward, and then syringe into 
the upper nostril, allowing the fluid to escape through the lower. 
The nozzle of the syringe should be fitted well into the nostril, and 
the stream thrown slowly and gently into the cavity. If the parts 
are so completely occluded that a stream of water cannot be made to 
pass around from one nostril to the other, our dependence will be 
upon the local application of the disinfecting fluid by means of a 
pledget of cotton wound upon a slender probe and gently passed into 
the cavity. This manipulation should be accomplished with great 
care. 

As before intimated, I believe that nasal diphtheria always results 
from the extension of the membrane from the naso-pharynx. When 
this latter cavity is involved, it is best medicated, probably, by means 
of a curved probe inserted through the oral cavity, using the solution 
of iron to arrest the exudative process and the bichloride solution for 
disinfecting purposes. In using the perchloride or persulphate of 
iron in the naso-pharynx, it is to be borne in mind that these parts 
are exceedingly sensitive ; and it is well, in making this application, 
to dilute the officinal liquor with from two to four parts of glycerin, 
thus not only reducing the strength of the solution, but forming a 
thick and syrupy fluid, which is less apt to drop to the parts below. 

Internal Medication. — The most important indication, probably, 
for the internal administration of remedies in an attack of diphtheria 
lies in sustaining the vital forces and counteracting as far as possible 
the toxaemia. Alcohol, in the shape of whiskey or brandy, presents 
us with a remedy which is, perhaps, as nearly a specific against sep- 
tic infection as any that we possess. This should be given as soon 
as there are any indications of systemic prostration. For a child 
five years of age, suffering from diphtheria, the administration of 
from six to eight ounces of whiskej^ daily would probably not be ex- 
cessive, although this must be governed mainly by the general con- 
dition of the patient, as evidenced most clearly in the heart-action as 
shown by the pulse. The spirit should be administered at intervals 
of from two to three hours. 

While our main reliance will be on some form of alcohol, its stim- 
ulating action may be increased by the use of carbonate of ammonia 



486 DISEASES OF THE FAUCES. 

in small doses frequently administered. If the heart's action is 
weak, this tendency should be corrected by the administration of 
digitalis. If this is not well tolerated, convallaria or strophanthus 
may be resorted to. Digitalis and strophanthus in combination in 
many cases seem to give better results than when the drugs are 
administered singly. The use of the tincture of iron I regard as only 
second in importance and value to the administration of stimulants. 
This should be incorporated with glycerin in the proportion of one 
to eight, and should be given without dilution. To a child five 
years of age, a half-teaspoonful dose may be given every two or three 
hours. In this manner we get both the local and constitutional action 
of the drug. Whether this drug exerts any influence upon the poison- 
ous ptomains in the blood can only be a matter of speculation. Cer- 
tainly it exerts a specific action on that blood condition which we call 
hyperinosis, under the influence of which fibrinous exudations de- 
velop on a mucous membrane. 

The mercurial treatment of the disease consists in the administra- 
tion of the drug in large and frequently repeated doses from the very 
onset of the attack, thus bringing the patient completely under its 
influence as quickly as possible. I quite agree with the view that 
mercury is not to be regarded as a specific in diphtheria, and doubt 
whether the mercurial treatment has any influence upon the disease 
germs of diphtheria, but I am of the opinion that its action is mainly 
in controlling the tendency to membrane formation in the fauces and 
especially in the larynx and trachea. Jacobi makes the still further 
point that the separation of the false membrane in the trachea and 
bronchi is promoted by the use of the drug. We will probably get 
the best results from the administration of either calomel or the 
hydrargyrum cum creta in the full physiological dose, repeated every 
two hours for the first twenty -four hours, and subsequently at longer 
intervals, according to symptoms. 

Turpentine is another remedy which is supposed to have a definite 
specific action on the disease. It may be given suspended in milk in 
the form of emulsion, or pure. 

The bromine treatment consists of the internal administration of 
the drug in connection with its local application to the membrane in 
the fauces. If we base our judgment on the results of treatment as 
recorded in medical literature, we must regard the bromine treatment 
as secondary in efficacy to either the turpentine or mercurial methods. 

General tonics may occasionally be indicated. Of these, prefer- 
ence will undoubtedly be given to quinine. This is best administered 
in the form of a suppository, not at regular intervals, but as indica- 
tions present. 



DIPHTHERIA. 487 

Chlorate of potash is frequently incorporated with the iron prepa- 
rations for some supposed action that it exerts upon the local process 
in the fauces, but more especially perhaps for its oxygenating powers. 
The deleterious action of this drug on the kidneys should always be 
kept in view. When we consider the uncertainty of its action, it 
would probably be better omitted in most cases. 

Inhalations. — Inhalations from lime have for a long time enjoyed a 
well-deserved reputation for use in cases in which the membrane has 
developed in the larynx, the method consisting in throwing unslaked 
lime into water, the slaking process developing steam, which is con- 
veyed to the patient by means of a suitably constructed tent or cone. 
The theory is that the steam as it arises carries small particles of 
lime with it, and that these have a beneficial action upon the false 
membrane. 

Sprays. — The practical value of these applications is probably 
limited entirely to the use of antiseptic agents ; and for this purpose, 
in the order of preference, there may be applied bichloride of mer- 
cury, 1 in 5,000; phenol, 1 in 200; boric acid, 1 in 20; thymol, 1 in 
1,000; oil of eucalyptus, 1 in 1,000, and peroxide of hydrogen. 
These solutions cannot be expected to penetrate the parts sufficiently 
to exert any controlling influence upon the morbid process in the 
deeper tissues. 

Tracheotomy and Intubation. — In a large proportion of cases, 
despite all efforts at arresting the disease, the false membrane devel- 
ops in the larynx and the parts below, giving rise to suffocative 
symptoms. 

The measures already enumerated for the arrest of the disease 
failing, our only remaining resource practically consists either in 
opening the air passages or in the insertion of an intralaryngeal tube. 

Regarding the question as to when operative interference shall 
be resorted to, no definite directions perhaps can be given, further 
than to say that interference must be regarded as imperative in those 
cases in which, other remedies failing, the laryngeal disease is pro- 
gressive, as shown by the increase of dyspnceic symptoms. It is 
scarcely necessary to emphasize the point that very grave dangers 
are incurred by delaying operations, as the teaching of clinical ex- 
perience in this direction is almost universal that a larger proportion 
of cases are saved by an early tracheotomy or intubation than when 
these measures are resorted to after the vital forces have been notably 
depressed, not only by the persistence of the blood poisoning, but 
by the defective oxygenation which the laryngeal process entails. 
The relief of dyspnoea, whether by intubation or tracheotomy, 
of course exerts no direct influence upon the extension of the mem- 



488 DISEASES OF THE FAUCES. 

brane; and after an operation, as we know, a majority of patients 
succumb to asphyxia, a stenosis subsequently developing from the 
pseudo-membranous deposit in the trachea and bronchi. Notwith- 
standing this, immense relief is afforded in most cases by the opera- 
tion, and a fatal issue postponed. When we consider, therefore, the 
simplicity of the measure and the slight danger to life which can be 
directly attributed to the operation itself, there should be no question 
as to the propriety of resorting to it early in any given case of laryn- 
geal invasion. 

Hygienic Management of the Sick-Boom. — The arrangement of the 
sick-chamber in a case of diphtheria should be based on our knowl- 
edge that the specific germ possesses great vitality. 

All individuals who are in any degree susceptible to the disease, 
especially young children, of course should be removed from all pos- 
sible source of contagion. The attendance upon the patient should 
be limited, and all intercourse between such attendants and other 
individuals in the house should be forbidden as far as possible. All 
rugs, hangings, and upholstered furniture should be removed from 
the room, the dress of the attendants should be restricted to cotton 
and linen, and the bedding of the patient should be limited as much 
as possible to linen or cotton sheets and woollen blankets. 

Unquestionably the most important and efficient method of con- 
trolling the dissemination of the micro-organism consists in the thor- 
ough disinfection of every article which can possibly convey the germ 
from the body of the patient. A vessel containing a solution of cor- 
rosive sublimate, 1 to 1,000, should be kept readily at hand, into 
which the patient should expel all the saliva or sputa that escapes 
from the mouth. Every handkerchief, sponge, or towel which is used 
about the face of the patient should be immediately thrown into such 
a solution, as well as any clothing removed from the body. The 
vessel that is used for fecal evacuation should also contain an abun- 
dant supply of the disinfectant fluid. The hands and face of the 
patient as well as those of the attendants, should be disinfected in the 
same manner. 

The further hygienic measures which should be observed consist 
in keeping the room at a temperature of about sixty-eight degrees, 
and having the atmosphere fully surcharged with moisture by means 
of a steam apparatus. Proper ventilation is of special importance 
in diphtheria, not only for its direct influence upon the patient, but 
also as allowing an exit into the outer air of the disease germs. 

After convalescence is fully established, the patient is removed 
from the room, and all sheets, blankets, pillow cases, and other 
material of this kind are thoroughly disinfected by the mercurial 



DIPHTHERIA. 489 

solution, and the room itself, with the mattresses, etc., fumigated by 
burning sulphur. The presence of a certain amount of moisture in 
the room adds notably to the efficiency of the sulphur fumes. 

Sequelae. — The most common of all the sequelce which result from 
an attack of diphtheria are paralyses involving certain muscles or sets 
of muscles scattered throughout the body. The paralysis is the 
direct result of a neuritis involving either the terminal filaments, the 
trunk of the nerve, or the ganglionic cells of the spinal cord. This 
neuritis, moreover, is set up by the action of the poisonous ptomains 
in the blood. 

In the order of frequency, the paralytic sequelce of diphtheria occur 
in the ciliary muscle of the eye, the palatal muscles, the motor 
muscles of the eye, the muscles of the lower extremities, the muscles 
of the upper extremities, the muscles of the trunk, and the sphincters. 
The loss of tendon reflex is also perhaps to be classed among the 
paralyses. These paralyses may develop as early as the third day of 
the attack, or may be postponed until convalescence is established, 
and in rare instances ma3' be delayed for some days after. The ex- 
tent and duration of the paralysis bears no relation whatever to the 
severity of the diphtheritic attack, as a severe and prolonged paralysis 
may follow an exceedingly mild type of the disease. 

As a rule, diphtheritic paralysis is not considered a very grave 
complication of the disease, and does not entail any very serious 
danger, except in those cases in which the respiratory apparatus is 
involved, in which there may arise a troublesome bronchitis. 

Cases of paralysis of the diaphragm have been reported which 
terminated fatally. 

The affection tends to get well of itself, in periods varying from 
three to six weeks, although undoubtedly the recovery is hastened by 
the administration of general tonics, such as barks and iron, with the 
addition of strychnine in appropriate doses. If the paralysis is per- 
sistent, the direct application to the weakened muscle of the continu- 
ous current of electricity will be found of material assistance, unless 
a better reaction is obtained from the faradic. 



Intubation and Tracheotomy. 

When it becomes necessary to give relief to increasing dyspnceic 
symptoms which threaten suffocation, we have two resources, intuba- 
tion and tracheotomy. The considerations which weigh in favor of 
intubation are : the simplicity of its performance, the avoidance of a 
cutting operation, and the retention of a larger portion of the normal 
respiratory tract for breathing purposes. The objections to intuba- 



490 DISEASES OF THE FAUCES. 

tion are : the narrowness of the tube, the danger of its becoming oc- 
cluded by the excessive secretions, the difficulty of retaining it in situ, 
and the fact that, impinging upon the mucous membrane in a state of 
diphtheritic inflammation, it is liable to cause erosions whereby a 
more open avenue is established for the entrance of disease germs into 
the blood. 

The considerations which would seem to favor tracheotomy are 
that the air passages are open at a point farther distant from the 
primary exudation, and therefore in a situation less liable to be in- 
vaded, and that, the trachea being opened, easier access is obtained 
for local medication in case the false membrane extend to this region. 
As against tracheotomy there is the surgical operation with the ad- 
ministration of an anaesthetic, and the entrance of air directly into the 
trachea with the practical abolition of the important portion of the 
respiratory apparatus above, thus entailing an additional danger of 
the supervention of bronchitis and perhaps of pneumonia. 

Without discussing at length these various considerations, their 
comparative value can only be practically established by reference to 
the results obtained by resort to the different methods of procedure. 

In statistics which do not regard the age of the patient we find 
that practically the percentages of recoveries in the two operations is 
about the same; in tracheotomy it being 27.14 per cent, while in 
intubation it is 27.2 per cent, taking the latest statistics. 

If, however, we examine the statistics compiled with reference to 
the age, we find that a greater proportion of children under five years 
of age can be saved by intubation. This has been brought out by 
the statistics of Stern and Bourdillat. 

Comparing these statistics, we find that intubation performed on 
children under two years of age gives us a gain of 12.5 per cent; 
between two and two and a half there is a gain of 12.5 per cent; be- 
tween two and a half and three and a half there is a gain of 11.9 per 
cent ; between three and a half and four and a half there is a gain of 
3.7 per cent; between four and a half and ^.\e and a half, a loss of 6.7 
per cent; and over five and a half there is a loss of 2.2 per cent. 

It seems clear that intubation promises the best results in chil- 
dren under four years of age ; between four and five a decision should 
be based mainly on the consent of the parents, the surroundings of 
the child, and other considerations. After the age of five, trache- 
otomy promises a better hope of saving the patient. 

If there is any indication that the exudation has invaded the 
trachea and air passages below, intubation affords even less hope of 
relief than tracheotomy. I am disposed to think that a patient is 
safer from accident with a tracheotomy tube properly inserted than 



DIPHTHERIA. 491 

with an intralaryngeal tube, when the skill and discretion of the 
attendant cannot be depended upon. 

It is my belief, however, that the number of lives which have been 
saved by the introduction of this method by O'Dwyer is far greater 
than is suggested by a comparative study of the statistics of intuba- 
tion and tracheotomy. 

A complete set of O'Dwyer's instruments for children consists of, 
first, six tubes of different sizes, and varying from one and a half to 
two and a half inches in length; second, an introducer; third, an ex- 
tractor; fourth, a mouth gag, and fifth, a scale. 

The tube is an ovoid cylinder, bulging at its centre, and is fitted 
with a rounded head at its upper extremity, which lies upon the 





Fig. 109. — Inf reducer with Tube attached ready for Use. 

ventricular bands when in situ, thus preventing the instrument from 
falling into the trachea. The anterior angle of the head is perforated 
for the insertion of a cord, whose use is for the prompt recovery of 
the instrument in case of failure to properly insert it in the larynx, 
the blocking of the tube by detached membrane, or other accident. 

The introducer (see Fig. 109) consists of a long slender rod fitted 
with a handle. Outside of the rod is a sliding tube, operated by the 
button seen on the upper surface of the handle. The distal extremity 
of the introducer is a long jointed rod, curved to a right angle with 
the shaft, which passes completely through the intralaryngeal tube. 
That portion of the introducer which fits into the laryngeal tube is 
jointed in such a way as to facilitate its withdrawal. The object of 
the sliding portion of the introducer is to detach the laryngeal tube 
after it has been placed in the larynx. 

The extractor (see Fig. 110) is an instrument devised for withdraw- 
ing the tube when desired ; its action will be easily understood by 
the figure. It is constructed on the principle of the curved forceps, 
with the exception that the small blades seen at its distal extremity 
are in apposition. When this instrument is inserted into the upper 



492 



DISEASES OF THE FAUCES. 



end of the laryngeal tube, the small blades are opened by pressing on 
the lever, thus enabling the operator to withdraw the tube. The 
small set screw in the handle of the lever is to regulate the extent to 
which the blades are opened, especially with reference to the avoid- 




Fig. 110.— Extractor for o the Removal of O'Dwyer 's Tube. 



-12 — 



■7 — 



5-;4 



2 — 



1>-- 



ance of injury to the surrounding parts in case the instrument is in- 
serted outside of the tube. 

The mouth gag recommended by O'Dwyer is theDenhardt instru- 
ment (see Fig. Ill) , the handles of which are bent back 
in such a manner as to hamper the manipulation in the 
least degree. 

The scale (see Fig. 112) has been arranged by 
O'Dwyer to show the size of the tube best fitted for 
the different ages: thus, a tube reaching from the 
lower end of the scale to No. 1 is the size adapted for 
children a year old; to No. 2, for children two years 
old, etc. 

Method of Operating. — The child should be placed 
in a sitting position in the lap of an attendant, with 

the head resting 
firmly against the 
shoulder, the 
hands being held 
or firmly secured 
by a binder passed 
around the body; 
the gag is then in- 
serted into the left 
side of the child's mouth as far back as feasible; an assistant stands 
immediately behind the child, holding its head firmly and slightly 
elevating the face. The operator, standing immediately in front of 
the patient, with the introducer held lightly in his right hand, passes 
his left forefinger into the fauces and searches for the epiglottis, or 




Fig. 112.— The Scale. 



Fig. 111.— Mouth Gag. 



DIPHTHERIA. 

failing to find this, for the cavity of the larynx. As soon as he is 
convinced that the tip of the forefinger is beyond the epiglottis and 
immediately over the cavity of the larynx, the handle of the introducer 
is brought down upon the chest of the child, while the tube is passed 
back into the fauces along the side of the left index finger, acting as 
a guide. The handle of the introducer is then elevated, and at the 
same time the distal extremity of the tube carried backward along the 
index finger until it is immediately over the laryngeal entrance, when 
it is directed downward and carried quickly into position, the success- 
ful introduction of the tube being ascertained by the left index finger. 
As soon as the tube is in situ, it is detached from the introducer by 
pushing forward the sliding tube by means of the button on the upper 
surface of the handle, the manipulation being aided by the firmer 
grasp of the instrument, which is secured by the index finger on the 
small trigger which is seen on the lower side of the handle of the 
introducer. 

In withdrawing the instrument, the joint in that portion of the 
distal extremity of the introducer which fits into the tube enables 
the operator to extract it in an almost direct line, thus avoiding the 
awkwardness of manipulation which would otherwise be occasioned. 
During the removal of the obturator it is necessary to keep the index 
finger of the left hand on the shoulder of the laryngeal tube, to pre- 
vent its withdrawal with the obturator, and also to assist in the 
removal of the cord which has been attached to its rim. This, of 
course, should not be done until the success of the operation is 
demonstrated in the relief of dyspnceic symptoms. 

When we consider that this operation is done for the relief of one 
of the gravest and most distressing conditions which the physician 
is called upon to meet, and, furthermore, that in many cases the child 
is struggling and choking from imminent asphyxia, it is easy to ap- 
preciate how absolutely necessary for the success of the manipulation 
are great manual dexterity and perfect self-control. Each successive 
step in the procedure must follow promptly and without the slightest 
hesitation, and no time is to be wasted in searching for anatomical 
regions. The whole procedure should probably not occupy over from 
five to eight seconds, and if the first attempt fails it is better to give 
the patient an interval of rest rather than to prolong the effort beyond 
this period. 

The operation is not always unattended with accidents, such as 
the detachment of the membrane below the tube, whereby its calibre 
is occluded, the insertion of the tube into the oesophagus, and the 
laceration of the soft parts. The first of these accidents is one that 
cannot always be avoided; 'its occurrence is immediately recognized, 



494 DISEASES OF THE FAUCES. 

and necessitates the prompt withdrawal of the instrument, and in 
most instances the subsequent performance of tracheotomy. The 
insertion of the tube into the oesophagus may very easily occur 
from the failure to elevate the handle of the introducer sufficiently 
to bring forward the distal extremity of the tube. Such an acci- 
dent may be suspected if the tube passes down beyond the reach of 
the left index finger in the fauces, and, further, by failure to relieve 
dyspnoea. It is not an accident of any gravity, and simply demands 
a renewed attempt. Injury to the soft parts should occur only from 
rude and unskilful manipulation, and is scarcely a justifiable acci- 
dent, as the operator should always be assured of the position of his 
instrument at each stage of the manipulation. The accidents which 
may occur when the tube is in situ are its occlusion by secretion or 
detached membrane, ulceration of the soft parts, its expulsion during 
the act of coughing, interference with deglutition, and the entrance of 
food into the air passages during this act. If the tube becomes oc- 
cluded from any cause, it must be removed, cleansed, and reinserted. 
In case of failure to relieve the symptoms in this way, tracheotomy 
is the only further resort. Ulceration of the soft parts is the result 
of pressure from the collar of the tube, and also of pressure on the 
trachea by its lower extremity. It is not an accident of much gravity, 
and is usually the result of long-continued wearing of the tube. It 
can be obviated only by changing the shape of the tube and adapting 
it to the conditions that arise. The expulsion of the tube in the act 
of coughing cannot always be avoided, though it usually arises from 
the instrument being too small, in which case a larger and more closely 
fitting tube should be introduced. One of the gravest difficulties 
which is encountered is in the interference with the act of deglutition 
which the presence of the tube entails. This is one of the most diffi- 
cult features to overcome after intubation, and is present to a more 
or less well-marked degree in the large majority of cases. The only 
thing to do to meet this symptom, if it presents to such a degree as 
to prove a source of great annoyance, is to restrict nourishment 
largely to fluids, these being more easily expelled from the trachea 
than solids. If, however, they are taken very slowly, they may pass 
into the oesophagus without entering the larynx. Failing other 
measures, the child can be placed on its chest and made to draw 
fluids through a pipette. 

The length of time which the tube should remain in situ depends 
largely on the progress of the case as evidenced by general symptoms. 
If the febrile movement subsides and the tendency to formation 
of a false membrane in the fauces disappears, and convales- 
cence seems established, the tube should of course be removed. 



DIPHTHERIA. 495 

Practically, we allow it to remain as long as there is any dyspnoea 
to overcome. 

In one hundred and fifty -eight successful cases collated by 
O'Dwyer, the average time during which the tube was retained was 
five days and two hours ; in his own cases, the longest time was four- 
teen days and the shortest fourteen hours. He further states that 
the younger the patient the longer the tube will be required ; in chil- 
dren under two years it is rarely safe to take it out under seven days. 

The removal of the tube is generally considered a somewhat 
more difficult manipulation than its insertion. When this is to be 
done, the index finger of the left hand is passed into the laryngeal 
opening until the collar of the tube is felt in the larynx, when the 
extractor, held in the right hand, its distal extremity guided by the 
left forefinger in position, is passed along until it comes into position 
immediately over the upper extremity of the laryngeal tube, when it 
is passed into the aperture, and, its blades being separated by the 
pressure on the lever, the tube is grasped in such a way that it may 
be withdrawn. 



CHAPTER LXV. 

SYPHILIS OF THE FAUCES. 

The mucous membrane of the fauces seems to be a favorite site for 
the manifestations of syphilitic disease in its various stages. It is 
involved, probably, in a given number of syphilitic patients far more 
frequently than any other portion of the body, with the possible ex- 
ception of the skin. This is partially explained, perhaps, on the 
ground that the skin and mucous membranes are somewhat intimately 
associated, both from a physiological and pathological point of view. 
This, however, suggests no explanation of the fact that the mucous 
membrane of the upper air tract is more frequently involved than 
mucous membranes elsewhere. The principal reason of this is found, 
perhaps, in the near location of the parts to the outer world, and the 
frequency with which they are involved in chronic morbid processes, 
whereby the local manifestations of the specific disease are to an ex- 
tent encouraged. 

The manifestations of syphilis which we meet with in this region 
axe: first, the primary lesion; second, erythema of the fauces; third, 
the mucous patch ; fourth, the superficial ulcer ; fifth, gummatous 
deposits; leading to seventh, the deep ulceration of syphilis; and, 
eighth, cicatricial deformities. 

The Primary Lesion. 

The possibility of the entrance of the syphilitic virus into the 
blood through the mucous membrane of the fauces, as evidenced by 
the existence of a hard chancre in this region, would naturally be re- 
garded as exceptionally remote. An examination of the literature, 
however, shows us that it is by no means a rare occurrence. The 
mucous membrane of the palate, faucial pillars, and pharynx, pre- 
senting, as it does, a somewhat dense tissue coated with squamous 
epithelium, affords little opportunity for the entrance of the syphilitic 
virus. The surface of the tonsil, however, on the other hand, with 
the open mouths of its crypts, presents an exceptionally favorable site 
for the lodgement of the virus. Hence, the consideration of the 



SYPHILIS OF THE FAUCES. 497 

primary lesion in the fauces is confined practically to chancre of the 
tonsil. 

Etiology. — An erosion of the mucous membrane is usually con- 
sidered necessary for the entrance of the virus. This is not, I think, 
a common condition of the tonsil. Hence the suggestion is a plau- 
sible one that, the poison lodging in the tonsillar crypt, it sentrance 
into the circulation is aided by a certain permanency of contact. 

In many cases reported, the source of the disease was in impure 
practices, while in others it arose from kissing, the use of drinking- 
vessels, pipes, etc. 

The disease usually occurs in adults, but is more frequent among 
men than women. 

Symptomatology. — In most instances the chancre occurs upon an 
hypertrophied tonsil, which, as before stated, seems to prevent favor- 
ing conditions for the entrance of the virus. The local morbid pro- 
cess is usually of an aggravated character — more so than when the 
sore is situated upon the penis. 

The first symptom to which it gives rise is that of an aggravated 
sore throat, with pain in deglutition. This, in spite of ordinary 
treatment, increases in a marked way, Until the local symptoms are 
of a distressing character, the tonsil becoming notably enlarged as 
the result of the inflammatory action, which involves the tissues be- 
yond the borders of the local sore, while the pain becomes constant 
and assumes a lancinating character. 

Very early in the history of the disease, the submaxillary and 
cervical glands of the affected side are indurated. This cervical bubo 
is of a much more serious character than that which occurs in the 
groin, being larger and at the same time tender to pressure and 
painful. No case of suppuration, however, has been observed. 

Diagnosis. — The characteristic appearances which enable us to 
recognize a chancre of the tonsil are in the somewhat sluggish ulcer- 
ation which ensues, together with the induration surrounding it and 
the unilateral enlargement of the cervical and submaxillary glands. 
The lesion presents the ordinary appearances of chancre, with this 
exception, that in most instances it covers a wider area, involving 
more or less of the whole surface of the tonsil. 

The surface of the ulcer is granulated in appearance, of a grayish 
color, and is covered with inspissated mucus. There is ordinarily 
no evidence of destruction of tissue, although the ulcer has been 
known to take on something of a phagedenic character. The indura- 
tion usually involves the whole of the tonsil, and is thus somewhat 
dependent upon the amount of hypertrophy of which the organ is 
the seat. If the lesion is a small one, we meet with the ordinary 
32 



498 DISEASES OF THE FAUCES. 

button-like induration of chancre of the penis. The surface of the 
ulcer is usually flush with the surrounding tissues, and hence pre- 
sents none of the appearances met with in the gummatous ulcer of 
syphilis. 

If there is any doubt in the diagnosis of a given case, the early 
appearance of the eruption will serve to clear it up. This may be 
looked for in from two to four weeks after a primary lesion in this 
locality. The secondary eruption, moreover, is in many instances 
of a papular character, still further indicating a certain activity of the 
virus, in that a cutaneous syphilide of this variety is usually post- 
poned until the third or fourth month. 



Eeythema of the Fauces. 

This manifestation of syphilis belongs usually to what is called 
the secondary stage, and occurs from six weeks to four months after 
the primary lesion. It consists of a peculiar discoloration of the 
mucous membrane of the fauces, which presents certain appearances 
that are almost characteristic of specific disease. The discoloration 
of the membrane seems to consist of a passive hyperemia, in which 
the veins seem to take the prominent part. In consequence of this, 
the color of the membrane is of a dark red, slightly verging on a 
purplish hue. This appearance is attended with no perceptible 
swelling of the part, nor is there any notable hypersecretion. 

The eruption confines itself entirely to the soft palate and pillars 
of the fauces, the posterior wall of the pharynx not being usually in- 
vaded to any perceptible extent, although it may be the seat of a cer- 
tain amount of discoloration. 

The appearance which is characteristic of specific disease, and 
which differentiates this eruption from any other with which I am 
familiar, consists of the sharp line of demarcation between the affected 
membrane and the healthy tissue beyond. This appearance I regard 
as almost pathognomonic of syphilitic erythema. The discoloration 
is of a uniform dull red color. 

In many instances the tonsils are also invaded by the eruption, 
and present a slightly swollen appearance with the same peculiar 
change in color. This, however, is not the invariable rule. 

The onset of this condition is somewhat insidious, and usually 
gives rise to no symptoms which would call attention to any local 
disorder in the fauces. In most instances, probably, it is discovered 
on an inspection of the throat for diagnostic purposes. 

While the eruption usually appears in connection with a cutaneous 
erythema, it may also occur coincidently with a papular or erythe- 



SYPHILIS OF THE FAUCES. 499 

mato-papular syphilide. According to Mauriac, where we have the 
cutaneous erythema assuming a circinate or annular form the same 
appearance is reproduced in the faucial eruption. 

An erythema of the fauces, then, is closely analogous and prac- 
tically the same as the cutaneous erythema. Mauriac recognizes a 
still further analogy in the desquamation which occurs from the 
faucial mucous membrane with the subsidence of the eruption. 

The Mucous Patch. 

This is one of the earliest and most persistent of the specific mani- 
festations with which we meet in the fauces. It is usually classified 
as belonging to the secondary stage of the disease ; and although it 
is more frequently met with in the earlier stages of syphilis, it may 
occur at any period. The usual period for its first occurrence is from 
six weeks to three months after the primary sore. It bears no direct 
relation to any individual cutaneous eruption, but manifests itself 
quite independenth' of them. According to Keyes, it occurs usually 
in connection with papular eruptions of the skin, and may outlast 
several crops of the different eruptions. It is of course a local mani- 
festation of the blood poison. While, as before stated, it most 
frequently develops in the early history of the disease, it would seem 
that there is no period of syphilis which is exempt from its occur- 
rence. 

The mucous patch is probably by far the most contagious of all 
secondary manifestations of specific disease, and is quite as contagi- 
ous, if not more so, than the primary sore. Moreover, direct contact 
is not necessary for transmission, in that the saliva and mucous secre- 
tions of the mouth may convey the contagious material. In discuss- 
ing, in a former chapter, the question of the transmission of syphilis 
to offspring, the view was taken that this was impossible if three 
years had elapsed in either parent after the occurrence of the primary 
sore. If this be true, it must follow that, after the lapse of a similar 
period from the primary lesion, it is impossible to convey the disease 
to another through the secretions of any of the various local lesions. 
Hence, while the earlier mucous patch is exceedingly contagious, 
those which occur later than three years must be regarded as innoc- 
uous in this respect. 

Symptomatology. — The presence of these patches ordinarily gives 
rise to no very marked subjective symptoms other than a sense of 
discomfort and stiffness in the parts, which is aggravated by the act 
of deglutition. Their special feature consists in their acute sensi- 
bility, under which they become exceedingly painful to the impact of 



500 DISEASES OF THE FAUCES. 

even mild and unirritating food or drink, and may even become so 
distressing as to interfere with proper taking of nourishment. 

Diagnosis. — In its early stages, a mucous patch presents as a 
small, bluish- white, opalescent area lying upon an apparently healthy 
mucous membrane. Being the result of an infiltration, the membrane 
is naturally to a slight extent thickened at this point, although this 
is not ordinarily appreciable on inspection. In appearance, it so 
closely resembles an area of mucous membrane which has been re- 
cently touched with a stick of nitrate of silver that even an experi- 
enced observer might find it difficult to distinguish between the two 
conditions. A single patch is something of a rarity, in that they 
usually appear in groups of small patches, scattered about on one or 
the other side of the fauces. The early patch usually makes its ap- 
pearance, somewhat in the order of frequency, on the soft palate and 
uvula, the anterior face of the anterior pillar, the face of the tonsil, 
and the anterior face of the posterior pillar. It never is seen on the 
pharyngeal wall. 

It is now universally accepted that syphilis is not auto-inoculable, 
and yet, in connection with mucous matches in the fauces, we very 
frequently meet with a somewhat curious and yet characteristic appear- 
ance, in which a chain of mucous patches on one side of the throat 
has been exactly reproduced on the other side, giving rise to what 
has been called the Dutch-garden aspect of faucial mucous patches, 
so named because the group presents an absolutely symmetrical ap- 
pearance on both sides. It is the universal teaching that an inocula- 
tion of the secretions of a mucous patch can only give rise to a 
primary sore. In the case of the mucous patch, therefore, we must 
content ourselves with the view that the frequent contact of the patch 
on one side of the fauces has given rise to a similar condition on the 
opposite side, without regarding it as evidence of the auto-inocula- 
bility of the disease. 

If the disease has persisted for some time the patches and the 
surrounding membrane become thickened and indurated and in con- 
sequence of the frequent movements of the parts, cracks and fissures 
form which easily bleed. This is especially true when the disease 
occurs on a fold of mucous membrane, as on the edges of the palate 
or faucial pillars. 

This condition constitutes what is generally known as the scaly 
patch, and may develop from the soft, smooth patch of the early 
stages of the disease as the result of its persistence, or it may be met 
with in the later stages of the disease, ^\e and even ten years after 
the primary sore. In this stage also we find it making its appear- 
ance on the posterior wall of the pharynx for the first time. 



SYPHILIS OF THE FAUCES. 501 

Course and Prognosis. — This local manifestation of syphilis is 
probably one of the most obstinate with which we have to deal, for, 
although quite amenable to local and constitutional treatment, these 
patches frequently recur with a persistence which is oftentimes 
equally annoying to the patient and the physician. This is especially 
true of the scaly patch, which occurs in the later stage of syphilis. 

The ordinary mucous patch shows no marked tendency to undergo 
ulcerative action. When, however, it has developed into the thick 
broad and scaly patch, as the result of persistency or under the local 
irritating influence of alcohol, the use of tobacco, or some other cause, 
the activity of the cell proliferation becoming thereby increased, 
tissue necrosis is liable to occcur, whereby the whole mass breaks 
down into ulcerative action, giving rise to the superficial ulcer of 
syphilis. 

The Superficial Ulcer. 

This form of ulcer is usually regarded as belonging to the secon- 
dary period of syphilis, and is met with in from one to three years 
after the primary lesion. As before stated, it may occur as the re- 
sult of the breaking down of tissue in the erosive mucous patch. 
This, however, is not its ordinary method, for in the very large 
majority of instances it undoubtedly results from the breaking down 
of a gummatous deposit. 

The essential pathological lesion which gives rise in the one case 
to a mucous patch, in another case to the superficial ulcer, and still 
later to a deep ulcer, is practically the same in all, the only difference 
being in the extent of tissue involved. In the mucous patch the in- 
filtration is very superficial, and shows little tendencj' to ulceration. 
In the superficial ulceration, on the other hand, the infiltration ex- 
tends into the deeper tissues of the mucous membrane, and early 
ulceration is the rule. Again, in the deep ulcer the infiltration ex- 
tends not only into the mucous membrane, but into the tissues 
beyond, and in breaking down gives rise to the peculiar crater-like 
ulcer of late syphilis. 

No special reason can be assigned for the occurrence of this form 
of ulcer other than that the specific virus which constitutes the dis- 
ease, reproducing itself in the blood, increases in intensity in such a 
way that as the years go by a localized outbreak in the faucial mucous 
membrane assumes a more active type. 

In the order of frequency, it is met with on the tonsil, the soft 
palate, the anterior pillar, and the plica salpingo-pharyngea. In one 
or two instances I have observed it on the upper surface of the soft 
palate, an exceedingly rare location. 



502 DISEASES OF THE FAUCES. 

It usually occurs in a somewhat elongated ovoid form, and shows 
but slight disposition to extend. Moreover, as in other forms of 
ulceration in this region, there is a notable hesitancy in transgressing 
anatomical boundaries. The primary gummatous deposit, occurring 
as it does in soft yielding tissues, gives rise to no marked symptoms 
which direct attention to any lesion in the throat. Moreover, it is 
probable that the ulceration follows so rapidly upon the deposit that 
the occurrence of the latter might be easily overlooked. 

When the ulcer has fully developed, the patient is conscious of a 
sense of uneasiness and stiffness in the parts, with a certain amount 
of dysphagia. This latter symptom is somewhat dependent upon the 
location of the ulcer. 

Diagnosis. — The recognition of these ulcers is ordinarily quite 
simple, by ocular inspection. 

As already stated, I do not believe these ulcers possess any 
notable tendency to extension. This is due to the fact that the whole 
of the primary gummatous infiltration breaks down and disappears 
in the ulcerative action. If neglected, the ulcerative process may per- 
sist for a considerable period, and, acting as a point of local irrita- 
tion, undoubtedly serve to invite to this point a new deposit of gum- 
matous material, and as a result there occurs an extension of the 
ulcer. In other words, I do not believe that syphilitic ulcers extend 
by a progressive infiltration of the tissue with gummatous material, 
but rather by periodical explosions, as it were. 

The Gummy Tumor. 

This term, in the present consideration, is restricted to those rare 
instances in which the infiltration of the tissues with gummatous 
material assumes the form of a distinct tumor of the fauces. 

In the very large majority of instances, when the deeper tissues 
become the seat of a gummatous infiltration the breaking down 
occurs so rapidly that when the case comes under observation it pre- 
sents as the deep ulcer rather than as the gummy tumor. In rare 
instances, however, the breaking down is delayed, and the case pre- 
sents itself in the form of a tumefaction ; hence it becomes a matter 
of some importance to recognize it as such, in order that the exten- 
sive destruction of tissue which the ulcerative process naturally in- 
volves may be avoided. It belongs to the later stages of syphilis, 
and occurs from five to fifteen years after the primary lesion. 

It is not easy to determine how long a gummy tumor may exist 
before ulceration. It is probably dependent on the location. A 
gumma of the posterior wall of the pharynx being necessarily subjected 



SYPHILIS OF THE FAUCES. 503 

to a great deal of mechanical irritation and pressure in the act of 
deglutition, it would seem that in this location it should break down 
quite early. 

According to Zeissl, the most frequent site for gummy tumors of 
the palate is on its posterior surface ; and when they develop here 
they may persist for quite a prolonged period of time, and escape 
observation until ulceration occurs. 

The symptoms to which a gumma of the fauces gives rise seem to 
be mainly those of mechanical interference with the function of the 
parts, both in deglutition and phonation. 

The pathological changes which constitute a gummatous deposit 
in the faucial mucous membrane differ in no essential degree from 
that involving the nasal mucous membrane. 

Diagnosis. — The recognition of a gummatous tumor of the fauces 
is always a difficult problem. The tumor is hard, dense, resisting, 
not especially painful to the touch, and unattended with any evidences 
of inflammatory action, the mucous membrane covering it being of a 
paler hue usually than the normal, the blood-vessels of the mucous 
membrane investing it being exsanguinated by the pressure of the 
tumor. In the soft palate it is usually a rounded symmetrical mass, 
while in the pharynx it may be somewhat irregular in outline, and 
usually is unilateral, except in the case of the broad superficial 
deposits. 

In the soft palate the main question of differential diagnosis lies 
in the exclusion of adenoma and fibroma, while in the pharynx it lies 
between fibroma, sarcoma, and carcinoma. These questions will 
necessarily be decided on the general appearances of the growth, to- 
gether with the clinical history in each individual case, and many in- 
stances will only be definitely determined by the experimental ad- 
ministration of antisyphilitic remedies. 

The Deep Ulcer of Syphilis. 

This lesion of syphilis is the direct result of the softening and 
breaking down of the gummy tumor, and therefore belongs essentially 
to what is termed the tertiary form of the disease. The extent of area 
and the depth of tissue involved, as we have before seen, are entirely 
dependent upon the extent and area of the original gummatous in- 
filtration. As before noted, the longer the period which has elapsed 
since the primary lesion, the deeper and more extensive are the gum- 
matous deposits liable to be. Hence, the extent of the ulcerative 
process is entirely governed by the extent of the original infiltration. 

We have already discussed the pathology and clinical history of 



504 DISEASES OF THE FAUCES. 

this form of syphilis, in connection with diseases of the nasal pas- 
sages, and what was there stated in regard to the disease in the nasal 
cavity is equally true in connection with the same lesion in the 
fauces. 

A gummy deposit comes on with great suddenness, involving a 
certain extent of tissue and giving rise to adventitious tumefaction. 
This, as we have already seen, may persist for a few hours, or in rare 
cases for a number of days, when the mass softens and breaks down, 
giving rise to an ulcerative process. 

It is a common belief that the ulcer extends by a more or less 
rapid process of erosion of tissue, under the influence of the syphilitic 
virus. This I believe to be a wrong view. If there is any extension 
of the margin of the ulcer, it is due to the fact that the cellular infil- 
tration in the periphery of the gumma is less dense than that of the 
centre, and hence, while the process extends, it is a slow process, 
but still entirely influenced by the previously existing gummatous 
infiltration. 

By far the most frequent site of this form of ulcer is the posterior 
wall of the pharynx ; next in frequency we find it in the soft palate 
and pillars, and lastly in the tonsils. If it attacks the pharynx, it 
rapidly involves the whole of this region, limiting itself at the pos- 
terior pillars laterally, the level of the larynx below, and the pharyn- 
geal tonsil above, although it is no rare event to find it extend- 
ing somewhat into the vault of the pharynx. I have never seen an 
instance, however, in which it involved either the nasal cavity or 
larynx by extension. 

When attacking the soft palate, it produces rapid destruction of 
the part, but still confines itself to the original deposit. In most 
instances it is unilateral, thus showing a hesitancy in transcending 
the median line. If it occurs in the tonsil, in rare instances it passes 
into the soft palate, although I regard this as an unusual event. 

In asserting that the ulcerative irrocess does not extend beyond 
the site of the original gummy deposit, the idea is intended to be 
conveyed that there is no new and progressive deposit of gummatous 
material beyond the site of the original ulcer. As evidence that the 
ulceration involves only the original gummy deposit, however, I have 
frequently seen, not only in the pharynx but in the soft palate, a 
deep ulcer limiting itself to a small portion of the organ, and which 
persisted for days and even weeks but showed no tendency to extend 
to the neighboring tissues. 

Symptomatology. — The occurrence of the ulceration usually gives 
rise to an aggravation of the symptoms which may have previously 
existed in a case of gummy tumor ; the pain on deglutition becomes 



SYPHILIS OF THE FAUCES. 505 

more marked and the movements of the fauces more hampered, while 
at the same time there is a very notable increase in the secretions of 
the part. The prominent symptom, of course, is pain on deglutition, 
while the other symptoms to which the disease may give rise are, de- 
pendent upon the character and location of the ulcer. If the palate is 
involved, this is very rapidly destroyed. Hence its function is abol- 
ished, and food and drink are liable to make their way into the nasal 
cavity. 

Serious hemorrhage as the result of destruction of blood-vessels is 
an exceedingly rare accident, although this possibility should be 
borne in mind. 

Articulation, of course, is interfered with, according to the loca- 
tion and extent of the ulcer. 

Diagnosis. — The appearances of this form of ulcer in the fauces 
are the same as those already described in connection with the nose. 

After the ulcerative process has exhausted itself in the throwing 
off of the gummatous matter, it is liable to assume a somewhat slug- 
gish although persistent form, in which there is but a limited effort 
at repair, owing probably to the systemic poison. Under the ad- 
ministration of remedies, however, the reparative effort seems to be 
characterized by great activity. 

Sequels. — If the disease attack the soft palate or tonsils, the only 
sequelae to be considered are the vigorous cicatrization and contraction 
of the tissue, with the resulting deformity. "When the ulceration is 
situated in the pharyngeal wall, in the very large majority of cases it 
extends through the whole depth of the mucous membrane, resulting 
in its complete destruction. A deeper involvement of tissue is an ex- 
ceedingly rare event, although the deposit may occur primarily in 
the vertebral periosteum, resulting in bony necrosis and this necrosis 
may even result in an exposure of the spinal cord. A further sequel 
may be a purulent meningitis. 

Cicatricial Deformities of the Fauces. 

I know of no lesion except those following burns which are suc- 
ceeded by more marked cicatricial contraction of tissue than the deep 
ulcer of syphilis in the fauces. When the ulceration has been slight, 
whether on the soft palate or pharynx, the reparative process results 
in a cicatrix which is characteristic. Our main interest in this con- 
nection, however, is confined to cases in which the ulceration has 
invaded such large areas of the fauces that, in healing, extensive 
cicatrices have resulted, and in contracting have produced notable 
deformity of the parts. 



506 DISEASES OF THE FAUCES. 

On first inspection of one of these cases, the impression is given 
that these abnormal adhesions and deformities are the result of union 
between two ulcerated surfaces, and that the condition has arisen from 
an involvement of the soft palate, pillars, and the wall of the pharynx 
in ulcerative action. If we study these cases more closely, I think 
we will find that the abnormal adhesions between the velum and 
pharynx are the result primarily of an adhesion of a normal palate 
or pillar to an ulcerated pharynx, or vice versa, perhaps. After the 
adhesions have occurred, the subsequent healing of the ulcer must 
be regarded as the main source of the extreme degree of deformity 
which is so frequently seen in these cases. 

A very common variety of deformity is an adhesion between the 
posterior faucial pillar and the pharyngeal wall. The condition 
gives rise to no very marked symptoms, for the palato-pharyngeal 
space is sufficiently wide to admit of free respiration, while the palate 
is still capable of performing its normal function. The only impor- 
tant symptom which may arise is an impairment of hearing on that 
side. This is due in part to a closure of the Eustachian tube and in 
part to an interference with the movements of the muscles which 
have to do with the renewal of air in the middle ear. 

Another deformity which may arise is caused by an ulceration of 
the soft palate, resulting in a more or less complete destruction on 
one or both sides. The cicatrization and contraction following give 
rise to an inflexible condition of this organ, the act of deglutition 
becoming impaired and fluids making their way into the nasal cavity. 
The voice also assumes a curious nasal twang, and articulation is 
markedly interfered with. 

By far the most common seat of the deep ulcer, as we have found, 
is in the pharyngeal mucous membrane, and hence the most frequent 
deformity is found to be adhesions between the soft palate and the 
pharyngeal wall. In this case there is usually not of necessity any 
loss of tissue of the soft palate, but the velum, becoming adherent to 
the pharyngeal wall, when the subsequent cicatrization and contrac- 
tion occur it is drawn downward and inward in such a way as to 
produce, not only more or less complete occlusion of the nasopharyn- 
geal passage, but also an asymmetrical condition of the parts. 

The original adhesion probably occurs in but a limited extent on 
the free border of the palate, but, as the palate is held in contact with 
the ulcerated surface, the amount involved in the adhesion increases, 
so that we may have the upper surface of the palate adherent to the 
pharynx for a considerable portion of its area. 

The uvula may remain pendulous, or it may be closely adherent 
to the pharynx and practically lost in the cicatrix. 



SYPHILIS OF THE FAUCES. 507 

If the condition lias resulted from a unilateral pharyngeal ulcer, 
we have simply adhesion of one side, with a very marked narrowing, 
as the result of contraction of the opening between the free portion of 
the palate and the pharyngeal wall of the opposite side. Occa- 
sionally we meet with complete closure of the palato-pharyngeal 
space. 

In the many cases of this form of adhesion which have come 
under my own observation, I have seen none in which complete 
closure has occurred, although many admitted only of the passage of 
a very small probe. 

The accumulation of the secretions in the nose, with inability to 
clear the passages, becomes a source of \eij great annoyance. The 
deformity involves serious discomfort and perhaps personal mortifica- 
tion, rather than any special danger, the most serious symptom, per- 
haps, being that of impairment of hearing. 

The special appearance of the throat which is characteristic of 
syphilis, of course, is the cicatrization with extensive contraction. 
The only lesion with which it could possibly be confounded Avould be 
lupus. In this latter disease, however, we meet with a nodular in- 
filtration, marked thickening of tissue, total absence of cicatricial 
contraction, as evidenced hy the presence of bundles of fibrous con- 
nective tissue with distortions, and furthermore we rarely, if ever, 
in lujms, meet with an ablation of the palato-pharyngeal space as the 
result of adhesions. Moreover, lupus of the air passages is generally 
accompanied by a similar lesion in some portion of the integument. 

The practical result of these deformities, if extensive, especially 
when located low down in the pharyngeal wall, is the formation of a 
stricture. If the ulceration has extended to the two pillars of the 
fauces, and they become adherent, the cicatricial contraction drags 
the tongue backward and downward, thus increasing the stenosis, and 
giving rise not only to obstruction in deglutition, but occasionally to 
dyspnoea. 

"When the original deposit with ulceration occurs in the soft palate 
and pillars and extends to the base of the tongue, we have a circular 
contraction, as it were, occurring at the isthmus, which may draw the 
tongue upward toward the palate, while at the same time the pillars 
are drawn inward, thus leaving a mere rounded opening at the en- 
trance of the pharynx, interfering with deglutition, but not neces- 
sarily with the entrance of air to the lungs. 

I know of no case in which the gummy tumor or the subsequent 
ulcerative process has extended by continuity of tissue into the 
oesophagus ; hence these pharyngeal strictures stop at the oesopha- 
geal orifice. 



508 DISEASES OF THE FAUCES. 



Treatment op Syphilis in the Fauces. 

The Primary Lesion. — The main interest of the hard chancre in the 
fauces attaches to the question of diagnosis. When recognized, how- 
ever, as we have already seen, the local ulcerative action is of a more 
active character than that usually met with in the penis. The con- 
trol of this destructive process, therefore, becomes an indication for 
treatment. This consists in thoroughly cleansing the parts by means 
of a simple lotion, after which the surface of the ulcer should be 
coated with iodoform or europhen. This process should be repeated 
daily. 

I doubt the efficacy of caustics, such as nitrate of silver and nitric 
acid, or the acid nitrate of mercury, in controlling the progress of a 
syphilitic ulcer of any variety, and should not indorse their use for 
this purpose. 

Internal medication should be deferred until the diagnosis is 
fully established by the appearance of the eruption or other secon- 
dary manifestation. 

The Erythema of the Pharynx. — The extent of the local inflamma- 
tion in this manifestation of syphilis is of an exceedingly trivial 
character, and rarely gives rise to any local symptoms. When pres- 
ent, they are of the ordinary catarrhal-pharyngitis type, and should 
be treated practically by the same methods as a non-specific inflam- 
mation. 

The Mucous Patch. — When a mucous patch makes its appearance 
in the fauces the case should be watched with the greatest care and 
the treatment followed up faithfully and with perseverance, for we 
have here to deal with one of the most persistent of lesions, and, fur- 
thermore, one in which there is a decided tendency to extension, not 
only by a continuity of tissue, but by the development of new patches. 
Furthermore, if not actively combated, it shows a disposition to be- 
come a chronic local affection of the faucial mucous membrane. 

The main indication for treatment consists in the thorough de- 
struction of the patch by the application of some efficient caustic 
agent ; and of these there is none better than nitrate of silver, either 
in the solid stick or saturated solution. This is to be carefully 
applied until each individual patch is thoroughly saturated with the 
caustic. The applications should be made daily, or at least every 
alternate day, until the morbid process is observed to be thoroughly 
under control. 

In addition to this, the use of alcohol, and especially of tobacco, 
should be strictly interdicted, while at the same time the patient 



SYPHILIS OF THE FAUCES. 509 

should be directed to avoid the use of all condiments, highly spiced 
food, etc. If the patches spread over a considerable area and give 
rise to much pain in deglutition, relief may be afforded by the local 
application of cocaine, a four-per-cent solution of which may be 
placed in the hands of the patient. Soothing gargles may be used 
with good effect. 

The Superficial Ulcer. — Both the local and general treatment of 
this manifestation of syphilis in the fauces is identical with that 
already given in discussing the treatment of a similar lesion in the 
nose. 

The Gummy Tumor. — The only difference between a gummy tumor 
in the fauces and that of the nose is that in the former situation it 
runs a much more rapid course, the tissue soon breaking down and 
giving rise to the deep ulcer. On account of its location in the 
fauces, however, it may give rise to prominent symptoms. 

The only method by which the tumor can be dissipated is by the 
internal administration of the iodides, in the manner already dis- 
cussed in connection with the gummatous tumor of the nose. 

The Deep Ulcer.- -This lesion of syphilis, when involving the nasal 
cavity, as we have already found, is usuallj' attended with bony 
necrosis, which markedly complicates its clinical history. In the 
fauces, however, we have to deal with an ulceration confining itself 
entirely to the soft parts, except in a few rare instances. Its treat- 
ment, however, is practically identical with that of a similar condi- 
tion in the nasal cavity, and consists in the early administration of 
full doses of the iodide of potassium, together with the local applica- 
tion of iodoform or europhen after the surface of the ulcer has been 
thoroughly cleansed. 

Cicatricial Deformities. — By far the most common deformity with 
which we are called upon to deal in this region is that in which the 
soft palate is adherent to the pharyngeal wall. 

The division of the adhesion, ordinarily, is a somewhat simple 
matter ; the great difficulty which is met with is in maintaining the 
artificial opening after it has been made. Various procedures have 
been adopted to prevent the readhesion of the parts, such as the 
suspension of lead or gutta-percha plates, or a series of drainage 
tubes by means of threads passed through the nose. These gave 
only indifferent results. Dilatation by means of Barnes' rubber bags 
was successful while the procedure was persisted in. 

Championniere constructed a curved silver tube, which was passed 
from below upward, between the palate and pharynx, and held in 
place by arms which were attached to the third molars of the upper 
jaw. This device seems to have been worn with comfort, and to have 



510 DISEASES OF THE FAUCES. 

answered an excellent purpose. Before resorting to his tube, Cham- 
pionniere had passed a rubber band into each nostril and round the 
palate, in order to maintain permanent traction. This, however, was 
without avail. 

A. H. Smith cauterized the cut surface by means of monochloro- 
acetic acid, the idea being thus to establish a superficial slough which 
would maintain itself in position for sufficient time to allow the edges 
to granulate beneath. I think experience teaches us that in most 
cases recontraction is the most serious difficulty with which we have 
to contend. While, therefore, Smith's device is a most ingenious 
one, and was attended with success in the case reported, it is scarcely 
available when there is a large amount of cicatricial tissue. The 
attempt has been made to dissect out the cicatrix. The necessary 
result, however, of such a procedure is merely a re-formation of the 
same tissue. 

The exceeding great deformity which characterizes these cases, 
together with the difficulty in dealing with them by ordinary proce- 
dures, naturally suggests the resort to some plastic operation. One 
of the most ingenious of these was that carried out by Lesser in a 
case in which the soft palate was adherent to the posterior pharyngeal 
wall, with the exception of a small portion in the median line. The 
portion of the palate not adherent to the pharyngeal wall was split 
into two plates, and the anterior of these divided in the median line 
by a longitudinal incision. The freshened surface of the posterior 
plate was then united to the angle between the two anterior flaps 
which had been formed by the preceding longitudinal incision. The 
adhesions between the velum and the posterior pharyngeal wall on 
either side were then divided, and each anterior flap was folded back- 
ward and upward over the raw surface thus formed, and sutured in 
this position. In this way the healthy mucous membrane covering 
the anterior face of the palate was made to face the raw surface on 
the posterior pharyngeal wall, and readhesion was thus prevented. 
While devices of this sort may be available in special cases, I think, 
as a rule, experience teaches us that a stricture here follows the same 
general law as stricture elsewhere, and demands constant attention to 
preserve a sufficient degree of patency for ordinary functional pur- 
poses. The ordinary rule of procedure, then, will be to separate the 
adhesions as far as possible by means of a properly curved or angular 
knife, after which the artificial opening is maintained by the daily in- 
troduction of such dilating instruments as may be best adapted for the 
individual case. In many cases in which the opening already exists, 
the whole treatment may consist in the use of dilating instruments, 
gradually increasing their size. As good an instrument, perhaps, as 



SYPHILIS OF THE FAUCES. 511 

we possess for dilating purposes is the ordinary flexible oesophageal 
bougie, which may be passed from above downward through the nose, 
or inserted through the mouth. The patients easily acquire suf- 
ficient dexterity to carry out this manipulation successfully. 

When the stenosis is of such a character as to notably interfere 
with respiration, tracheotomy would be demanded, and should, as a 
rule, be promptly performed as soon as the indications are present. 



CHAPTER LXVL 

TUBERCULOSIS OF THE FAUCES. 

It would seem that a deposit of miliary tubercle in the mucous 
membrane of the respiratory apparatus assumes a peculiar virulence 
according as the seat of the deposit is in portions near to the outer 
world. Furthermore, the frequency with which these tuberculous 
deposits occur seems to be governed by the same rule. In other 
words, while pulmonary tuberculosis is responsible for over one- 
seventh of the annual death rate among civilized nations, tuberculosis 
of the larynx is still less frequently met with, and tuberculous deposit 
in the buccal cavity is among the exceedingly rare manifestations of 
this fatal disease; but strange to say, while the frequency with which 
tuberculosis occurs diminishes in a marked way as we approach the 
outer world, it is also a noticeable fact that the severity of the dis- 
ease increases. 

Etiology.— The primary cause of faucial tuberculosis is the same 
as that of pulmonary or general tuberculosis. This subject, however, 
need not be entered upon in the present consideration. The active 
cause of the tuberculous manifestation in this region, undoubtedly, 
in the very large majority of instances, lies in a previously existing 
involvement of the pulmonary tissues. It has always been a subject 
of discussion, in connection with laryngeal phthisis, as to whether 
the primary deposit may occur in this region before the lungs are 
involved. The same question, of course, arises in connection with 
the pharyngeal affection, but from a practical point of view it is not 
important. That we may have a primary deposit of tubercle in the 
fauces, I think, should not be questioned. Primary tuberculosis may 
occur in any region or organ of the body ; there is no reason what- 
ever why it should not occur in the fauces. 

From a clinical point of view, however, I think it is exceedingly 
probable that coincident with the faucial deposit there occurs a pul- 
monary infiltration. A number of these cases has come under my 
own observation. In one reported it seemed to be pretty clearly evi- 
dent that the miliary deposit occurred in the pharynx, larynx, and 
lungs at about the same time. There was no autopsy in this case. 



TUBERCULOSIS OF THE FAUCES. 513 

The symptoms, however, pointed toward a general tuberculosis. The 
clinical history, furthermore, of the large majority of the cases re- 
ported is of a similar character. 

I think, then, we are justified in regarding faucial tuberculosis as 
a manifestation of acute miliary tuberculosis, the deposit occurring 
simultaneously in the pharynx, larynx, and lungs, together with the 
intestines and other portions of the body. Hence, a tuberculous 
ulceration in the pharynx or fauces should, as a rule, be accepted as 
evidence of general tuberculosis, the fact of the general systemic in- 
volvement being evidenced at the onset of the disease only by the 
marked constitutional symptoms, which, as will be seen later, are of 
a somewhat aggravated character. Furthermore, if physical signs 
give no evidence of involvement of other organs at the onset, or the 
bacillus is not found in the sputa, these manifest themselves so soon 
after the recognition of the faucial disease as to warrant the conclusion 
that a tuberculous infiltration has occurred simultaneously or imme- 
diately following the deposit in the tissues of the fauces. 

In the majority of instances the disease sets in in the course of a 
chronic pulmonary tuberculosis. 

While a question, perhaps, of no great practical importance, it 
has always been a subject of more or less discussion as to why tuber- 
culous ulcerations develop in the throat. 

Five cases of this disease have come under my own observation. 

In two of them it was exceedingly interesting to watch the new 
deposit of tubercle, which could be clearly seen making its appear- 
ance in small grayish-white nodules beneath the superficial layer of 
the mucous membrane, in such a way as to demonstrate conclusively 
to my own mind that the tuberculous deposit occurred before the ero- 
sion or ulcerative process. These minute nodules, furthermore, were 
easily identified and their clinical history traced, as in the course of 
from three to five days they broke down and showed ulcerative action. 

Strassmann's investigations possess a peculiar interest in this 
connection. He made a careful examination of the tonsils in 21 cases 
of tuberculosis ; in 15 of these cases the tuberculous process involved 
the lungs; out of these 15 cases of pulmonary disease 13 showed 
tuberculous deposits in the tonsils. In 6 cases of tuberculosis the 
lungs were not involved, and in all these cases the tonsils were not 
tuberculous; although subsequently 2 developed pulmonary disease. 
In the 13 cases of tuberculosis of the tonsil the source of the trouble 
was undoubtedly in auto-inoculation from the pulmonary discharges. 
The possibility of this is therefore proven as regards the tonsil. 
The entanglement of tubercle baccilli here, I take it, was largely 
mechanical. The tuberculous process, however, in these organs in all 
33 



514 DISEASES OF THE FAUCES. 

cases remained latent, no ulcerative action developing. This lends 
notable weight to the assertion already made that tuberculous ulcera- 
tion in the fauces is a manifestation of acute tuberculosis, and not of 
the chronic form of the disease. 

In view of the later pathological researches, we are compelled to 
recognize the fact that tuberculous disease is contagious. 

Pathology. — The pathological changes which characterize this 
disease in the fauces differ in no essential degree from tuberculous 
processes in other portions of the air tract. 

Of course the existence of the bacillus is recognized as an invari- 
able accompaniment of a tuberculous process. The primary deposit 
in the majority of instances occurs in the velum in the shape of mi- 
nute gray nodules, showing through the surface and causing slight 
grayish-white projections — the tuberculous nodule. These break 
down and form minute points of ulceration whose edges extend and 
join with their fellows, forming broad surfaces of diseased action. 
The extension of the disease is lateral to the pillars of the fauces and 
toward the pharyngeal walls. When the pharynx is the primary seat 
of deposit, the ulceration » shows a certain amount of hesitancy in 
ascending to the soft palate and pillars above. The ulcerative action 
commencing in the tonsil is very rare, and, furthermore, these tissues 
are not readily involved in the morbid process commencing elsewhere. 

In probably the large majority of cases the larynx is invaded by 
the tuberculous disease, if not coincident with, certainly very soon 
after, the faucial tissues are attacked. 

Symptomatology. — The onset of the attack is marked by the 
symptoms of ordinary sore throat; there is a sharp, lancinating pain 
in the fauces, aggravated on deglutition ; the parts feel sore and stiff, 
while at the same time the patient experiences a feeling of general 
malaise, with chilly sensations, or there may be a well-developed 
chill. Very early in the attack the thermometer shows a temperature 
of from 102° to 104° F., with the evening exacerbation characteristic 
of hectic fever. Deglutition becomes not only more painful, but is 
accomplished with considerable difficulty. The infiltration of the 
palate destroys its contractility in such a way that food and drink 
pass into the nasal cavities ; at the same time the general symptoms 
develop, the hectic sets in, the fever becomes more persistent, and 
there is progressive loss of flesh, both as a result of the constitutional 
disturbance and the difficulty of taking nourishment. The move- 
ments of the palate in the act of deglutition being thus hampered, 
the mucous and muco-purulent secretions from the ulcers accumulate 
in the fauces, and are expelled with great effort, increasing the dis- 
tress of the patient, who makes ineffectual attempts at clearing the 



TUBERCULOSIS OF THE FAUCES. 515 

parts by a feeble effort of hawking. The voice is thick and muffled, 
and articulation becomes difficult owing to the immobility of the 
fauces. The tone of the voice is not notably impaired unless the 
larynx is invaded. Cough is somewhat persistent, feeble, and in- 
effectual. The secretions from the ulcer are thick and exceedingly 
tenacious, adhering closely to the parts. These inspissated plugs, 
as it were, stretching from one side of the faucial bridge to the other, 
give rise to obstruction to breathing and also to a sort of gurgling 
noise on inspiration. 

After the faucial ulcerations are fully developed, these cases pre- 
sent a picture of suffering and distress that is pitiable in the extreme. 

Practically, then, we find that the general symptoms are those of 
acute miliary tuberculosis in connection with the local symptoms due 
to the ulceration in the throat. 

In rare instances tuberculosis in the fauces occurs in connection 
with chronic tuberculosis, when we find the same localized symptoms 
in the fauces, but not the marked systemic disturbance which charac- 
terizes acute miliary tuberculosis. These cases run a much slower 
course, and the clinical history, aside from the locality of the ulcera- 
tion, is mainly that of tuberculous laryngitis. 

Diagnosis. — Von Ziemssen in the discussion of laryngeal phthisis 
makes the assertion that neither the catarrh nor the ulceration of 
phthisical subjects presents any characteristic signs by which it can 
be recognized as such — a view which seems to have been adopted by 
Vivian Poore, Cohen, and others. Notwithstanding this, I believe 
that phthisical ulceration, whether observed in the larynx or fauces, 
presents certain features which are so characteristic of this form of 
disease that, practically, a diagnosis should not present any very 
great difficulties, especially when, as is the case in the fauces, the 
ulcerative process can be brought under direct ocular inspection. 

In the fauces two stages of the disease may be recognized : first, 
the stage of primary deposit, and second, the stage of fully developed 
ulcerative action. 

The two conditions need no further description here. Practically, 
there is but one disease with which phthisical ulceration may be con- 
fused, and that is the superficial or deep ulceration of syphilis. It 
is not necessary to give the points in the differential diagnosis ; for 
this may be settled by the determination of the presence or absence 
of the Koch bacillus. 

Course and Prognosis. — As before suggested, I think we must 
regard tuberculous disease of the fauces, in the majority of instances, 
as a local manifestation of general tuberculosis, in which case it will 
necessarily result in a fatal termination in the course of a very few 



516 DISEASES OF THE FAUCES. 

months. When it occurs in connection with chronic pulmonary 
disease, the prognosis is almost equally grave, although the fatal ter- 
mination is postponed somewhat. In this connection we consider it 
largely as a grave complication of the pulmonary disease, and one 
which adds notably to the suffering of the patient. 

Confining ourselves, then, to the consideration of the local dis- 
ease in the fauces, the question arises whether this is amenable to 
treatment. If, in a given case of pulmonary tuberculosis with faucial 
ulceration, the latter complication is cured, and the patient subse- 
quently dies of the pulmonary disease, I think it is a justifiable 
assertion to state that the pharyngeal tuberculosis was cured. Gou- 
genheim reports the case of a woman of twenty -five with an extensive 
ulceration of the soft palate and uvula, which was entirely cured by 
the regular application of iodoform and ether. The uvula was ampu- 
tated and showed tuberculous tissue, although there is no report of 
the tubercle bacillus having been found. There was no pulmonary 
disease, and the recovery is reported as permanent. Lennox Browne 
reports an instance in which a small ulceration appeared on the tonsil 
in a patient suffering with pulmonary and laryngeal phthisis. It 
disappeared after a single application of the galvano-cautery. Her- 
yng reports three cases of faucial tuberculosis occurring in adult life, 
in which the disease was a complication of pulmonary phthisis. The 
larynx was ultimately invaded in all these cases. The tuberculous 
ulcer was small and circumscribed, and was located on the pharyn- 
geal wall. It was entirely cured by Heryng's method of curetting 
and subsequently rubbing in lactic acid. 

We must accept, therefore, the teaching that in certain instances 
the small tuberculous ulcers in the pharynx which occur in connection 
with pulmonary disease may be amenable to treatment. In those 
cases in which the localized process is extensive in character, the 
prognosis is essentially unfavorable as regards even a slight amelio- 
ration of the local morbid action. In five cases reported children of 
from three to &ve and a half years were attacked and a fatal termina- 
tion occurred in from two to eight weeks after the first manifestation 
of the faucial disease. The majority of the cases reported occurred 
in adult life. In those in which the disease complicated a recognized 
acute miliary tuberculosis, the fatal termination ensued upon the 
pharyngeal manifestation in periods varying from two to four months ; 
while in those cases which simply complicated pulmonary phthisis 
the duration of life after the occurrence of the faucial deposit rarely 
exceeded six months, except those cases already mentioned in which 
the faucial disease was cured. 

Treatment. — Up to within comparatively recent years, practically 



TUBERCULOSIS OF THE FAUCES. 517 

the treatment of all forms of ulcerative action, including tuberculous, 
syphilitic, and others, confined itself mainly to the use of caustics, 
especially the solid stick of nitrate of silver, a proceeding not only 
useless but painful and distressing to the patient. 

The natural reaction which followed the abandonment of the use 
of caustics led to an entirely opposite mode of treatment, which con- 
fined itself to the use of mild palliative and soothing remedies. These 
consisted mainly in the application of certain cleansing lotions to re- 
move the mucous accumulations on the surface of the ulcer, after 
which there were applied mild, unirritating astringents, sedatives, 
and alteratives. The importance of this mild plan of treatment was 
first emphasized, so far as I know, in an article by the writer on 
laryngeal phthisis, in which the success was shown by a series of 
reported cases. 

The plan, definitely outlined, consisted of four steps, as follows : 
First, the thorough cleansing of the ulcerated surface; second, the 
application of a mild astringent; third, the application of an ano- 
dyne; and fourth, the application of iodoform, for its specific action 
in controlling an ulcerative process. The cleansing is accomplished 
by the use of a carbolized alkaline solution. Dobell's solution an- 
swers an excellent purpose. This is applied in all cases by means of 
an atomizer. The second stej) consists in the application of an 
astringent. In the order of preference these are : 

Zinci sulphas, ........ gr. v. to the oz. 

Argenti nitras, . . . . . . . . " iii. " 

Zinci chloridum, " iii. " 

The third step consists in the application of morphine in powder 
or in the form of Magendie's solution. The fourth step consists in 
the application of iodoform. This latter should be applied by means 
of Ely's powder blower. By this means a smooth, even layer of the 
powder is dusted upon the surface. This plan of treatment should 
be repeated every second or third day ; if the case is an aggravated 
one, daily applications will be required. The surfaces of these ulcers 
are exquisitely sensitive to the touch; hence the above plan of treat- 
ment is carried out in such a way that the diseased tissue is in no 
way impinged upon by instruments of any kind. The solutions are 
applied in a state of fine atomization, and the powders blown upon 
the surface. 

We find recorded in literature various recommendations for the 
use of inhalations by means of the steam atomizer or the ordinary 
inhaling apparatus which is used for volatilizing various medicinal 
preparations, such as oil of tar, iodine, creosote, benzoin, oil of eu- 



518 DISEASES OF THE FAUCES. 

calyptus, etc. I have never seen any advantage from the use of these 
measures in either pharyngeal or laryngeal tuberculosis ; and, further- 
more, I think as a rule that the steam or other hot applications are 
not well tolerated by a patieut suffering in this way, in that it causes 
a certain amount of relaxation of tissues with increased secretion, as 
a result of which the local symptoms are liable to be to a certain 
extent aggravated. The pain in deglutition is always a very promi- 
nent feature of these cases ; hence any measure which will enable a 
patient to swallow with comfort becomes of the utmost importance, 
as relieving suffering and at the same time serving to increase the 
amount of nourishment that can be taken. The local application of 
morphine adds very much to the accomplishment of this, perhaps ; 
but we possess no remedy which accomplishes this end with the 
certainty and facility of cocaine. As increasing its permanency of 
action somewhat, it is well to apply this suspended in one of the fluid 
petroleum oils. An excellent formula is the following: 

1$ Cocainse hydrochloratis gr. xx. 

Morphinae, gr. ij. 

Aquae, 3 ss. 

Misce ; ft. sol. Adde 

01. voschano . . . \ i. 

This may be used at the hands of the patient or by an attendant 
several times during the day, as may be indicated. 

While the above plan of treatment would seem to be largely pal- 
liative, yet in a number of instances, especially in laryngeal phthisis, 
I have seen notable results accomplished, not only in the retardation 
of the development of the local process, but in the marked improve- 
ment which occurred when the plan was faithfully and carefully 
carried out. 

Krause has obtained excellent results in the treatment of tubercu- 
lous ulcerations in the larynx by the application of lactic acid, and 
his method consisted in rubbing the lactic acid thoroughly into the 
diseased surface by means of a cotton pledget, or by injecting it by 
means of a hypodermic syringe directly into the tissues. He com- 
menced with a ten-per-cent solution, and gradually increased its 
strength if necessary up to eighty per cent, making daily applica- 
tions until local necrosis occurred. Krause claims that lactic acid 
will cause the sloughing of the diseased tissue only, and that the 
healthy tissue is not acted upon by the acid. He has reported a se- 
ries of cases of laryngeal phthisis in which this plan of treatment was 
followed either by cicatrization of the ulcer or by a marked improve- 
ment in the local condition. He reports no cases of faucial tubercu- 
losis treated in this way. Heryng, however, reports two cases of the 



TUBERCULOSIS OF THE FAUCES. 519 

pharyngeal disease treated by the lactic acid with entire success so 
far as the local conditions are concerned. Heryng's method differs 
from that of Krause in that the ulcerated surface is thoroughly cu- 
retted by means of a sharp sj»oon, thus removing as much of the dis- 
eased tissue as can be done in this manner, after which a strong 
solution of lactic acid is thoroughly rubbed into the tissues. In a 
third case by the same observer, an equally successful result followed 
the use of chloride of zinc in connection with lactic acid after the 
surface was curetted. 

Heryng reports almost equally good results in the curette and 
lactic-acid treatment of laryngeal tuberculosis, having succeeded in 
obtaining complete cicatrization in eight out of twelve cases. All 
these patients died ultimately of the pulmonary disease, and yet 
the laryngeal manifestation remained cured for periods varying from 
two to seventeen months. 

In another series of fifteen cases of laryngeal phthisis reported by 
Heryng, the treatment was by lactic acid alone, after Krause' s 
method. Eleven of these were completely cured. The natural infer- 
ence is that Heryng's curette does not add much to the success of the 
treatment, and that the remarkable results obtained were due entirely 
to the destructive action of the acid, in which we are compelled to 
recognize an agent which possesses peculiar powers in dealing with 
this most intractable disease, whether located in the pharynx or in 
the larynx. 

While, therefore, I am of the opinion that in most cases of tubercu- 
lous ulceration the soothing and palliative plan of treatment outlined 
above will be demanded for the relief of local symptoms, I think we 
have not done our full duty to any patient suffering from this dis- 
ease without giving him the benefit of such relief as lactic acid may 
afford, together with a hope of complete relief to the local conditions. 
I do not think that in resorting to the lactic acid we should abandon 
the other method. The methods are certainly not antagonistic, 
and I see no reason why in carrying out the milder course the more 
radical method with lactic acid should not be resorted to in those 
cases in which it can be used. 

Koch's lymph, introduced in 1890, was hailed with enthusiasm, 
but the claims made for its powers of controlling a tuberculous proc- 
ess were greatly over-estimated, and it has not proved of the value 
expected. 

Kosenberg reports a series of observations on fifty-seven cases of 
laryngeal phthisis, of which nine were cured by the use of menthol. 
He uses a twenty-per-cent solution of this drug in olive oil, apply- 
ing it to the ulcerated surface once or twice daily. The application is 



520 DISEASES OF THE FAUCES. 

made by dropping a few drops on the diseased surface by means of a 
small syringe, or it may be applied with an atomizer. In addition 
to this the patient is directed to inhale a few drops of the same solu- 
tion volatilized by boiling water, repeated several times in the course 
of the day. 

Knight reports having made somewhat extensive use of Rosen- 
berg's method, and, while reporting no cures, he finds it gives notable 
relief to the distressing symptoms of the disease. 

A case of Gougenheim's seems to have been cured by a saturated 
ethereal solution of iodoform. Ether is very irritating to the air 
passages ; and while regarding iodoform as an exceedingly valuable 
application in these cases, I think it should always be used in the 
form of a dry powder. 

There are certain other measures which are of importance, not so 
much for limiting the progress of the disease as for alleviating the 
distressing symptoms. These consist in the regulation of the char- 
acter of the food and method by which it is taken. Special apparatus 
has been devised for the artificial feeding of patients suffering from 
throat tuberculosis. We need not resort to these, however, for in my 
experience^ if the ulcerated surface be thoroughly cleansed by means 
of an alkaline spray and a five or ten per cent solution of cocaine 
thoroughly applied, it is rare to meet with a case of throat phthisis 
in which deglutition is not accomplished painlessly and effectively. 
This anesthesia persists usually from ten to twelve minutes, and can 
be repeated as often as it is desirable to administer food, which in 
these cases usually should be five or six times daily. 

The general treatment of tuberculosis does not demand full con- 
sideration in this connection. The constitutional treatment of throat 
consumption is practically the same as that of pulmonary consump- 
tion. This is so familiar to all that its discussion need not be 
entered upon here. 



CHAPTER LXVII. 

LUPUS OF THE FAUCES. 

In former years lupus was regarded as a disease which, under its 
two forms of lupus exedens and lupus non-exedens, confined its ravages 
almost exclusively to the skin, except in those instances in which the 
morbid process invaded the nasal cavities by extension. The possi- 
bility of its developing primarily or independently in the air tract 
seems to have been overlooked, and those cases in which the cutane- 
ous affection was accompanied by ulcerative disease of the fauces or 
larynx were regarded, especially by the French writers, as instances 
of strumous ulceration. Rayer was one of the earliest to suggest 
that the morbid process in the skin and the mucous membrane of the 
fauces were identical in character — a view in which he was followed 
by Hamilton, Cazenave, Alibert, and Devergie. 

Lupus, then, is a term which we use to describe a morbid con- 
dition which, while in the large majority of cases it attacks the skin, 
may also invade, either primarily or secondarily, the mucous mem- 
brane of the nose, pharynx, or larynx. 

Etiology. — It is difficult to assign any actively exciting cause for 
the disease. In certain cases of the skin affection, traumatism seems 
to have been the active cause of its primary development, and the 
disease of the air tract to have arisen secondarily to the cutaneous 
affection. In those rare instances in which the disease is primary 
in the fauces, no exciting cause can be suggested. 

Heredity does not seem to influence the disease, although un- 
doubtedly a constitutional condition which bears some relation to 
the tuberculous diathesis plays an important part in its causation. 
It is a generally accepted teaching at the present day that the special 
morbid lesion which constitutes lupus is due to a tuberculous deposit 
which is practically identical with that which gives rise to tuberculous 
disease of other organs. In one case, however, the morbid process 
is an active one, while in lupus the morbid process which the tubercle 
excites is an exceedingly chronic or latent one. 

In sevent3 r -nine cases in which lupus has invaded the air tract, 
which I have collated from medical literature, including those which 



522 DISEASES OF THE FAUCES. 

have been under my own observation, fifty-one occurred in females, 
while but eighteen occured in male patients, the sex not being re- 
ported in the other instances. 

As before stated, in the majority of cases the disease commences 
in the integument, and subsequently, at periods varying from one to 
ten or twenty years, invades either the fauces by new centres of de- 
velopment, or the nasal cavities, by continuity of tissue. When it 
extends to the fauces, it usually attacks the soft palate and pharynx 
first, and subsequently the larynx. 

The relationship between lupus and tuberculosis seems to be 
clearly established, both from a clinical and pathological point of 
view ; for while the two diseases appear to pursue a distinctly differ- 
ent course, they are coincident in the same individual in such a num- 
ber of cases that this clinical relation must be accepted. This 
teaching, however, does not seem to be borne out by a study of the 
cases of lupus in the air tract, for of these I find but one instance 
in which lupus of the throat occurred in a tuberculous subject, viz., 
that reported by Thoma. In compilations of cases, Bloch finds a 
tuberculous taint in over seventy-five per cent of his cases, Raudnitz 
in nine per cent, and Besnier in twenty per cent. It is not easy to 
harmonize these statement. It is probable, however, that Bloch has 
accepted, as evidence of tuberculous disease, enlarged lymphatic 
glands, caries, and other manifestations which are usually grouped 
under the indefinite term struma. 

While, therefore, the relation between the diseases seems clearly 
established from a clinical and pathological point of view, tuberculous 
disease of the lungs or other organs cannot be regarded as standing 
in a very active causative relation to lupus in the air passages. 

Pathology*. — The opinion broached by Neisser and Friedlander 
in 1881 that lupus constituted a true tuberculous process was very soon 
verified by the announcement of Koch that he had discovered the 
presence of the tubercle bacillus in lupus nodules. This view was 
still further confirmed by the experiments of Schuller, Doutrelepont, 
Koch, and others, who produced tuberculosis in the lower animals by 
inoculation of lupus tissue. Koch went still further, and produced 
pure cultures of tubercle bacilli from tissues invaded by lupus. 

The most common point of invasion of the disease when it attacks 
the fauces is the soft palate or one of the pillars. It usually starts 
near the free edge. A very common point of origin is in the body of 
the uvula. 

After the primary invasion, it extends slowly to neighboring tis- 
sues, without reference to anatomical boundaries, in this respect 
differing notably from syphilitic disease. From the soft palate it 



LUPUS OF THE FAUCES. 523 

extends to the pillars, involving the tonsils and finally the posterior 
wall of the pharynx. 

At the onset of the disease it seems to be one purely of infiltra- 
tion, producing that peculiar nodular thickening of the parts by 
which their normal contour is destroyed. The uvula is transformed 
into a thick, lumpy, bulbous mass, while the thin border of the soft 
palate is converted into a broad, somewhat ragged-looking, cord-like 
margin. 

In connection with the infiltration which takes place in the tissues 
of the palate and pillars, there soon sets in a process of ulceration, 
which results in a notable loss of tissue. The ulcerative process 
which characterizes lupus is a peculiar one, differing in a marked 
degree from every other form of ulcer. There is an enormous thicken- 
ing of the part from the primary and progressive infiltration, together 
with a slowly progressive recession or fading away of tissue ; and yet 
the secretion is exceedingly limited, there is no pus discharge, no 
cell proliferation, no detritus, no necrotic tissue, and on close inspec- 
tion in many instances a true ulcerated surface is not easily detected. 
In fact, none of the appearances which we ordinarily regard as char- 
acteristic of ulcerative action are present. This peculiarity may 
possibly be accounted for by the exceedingly chronic course of the 
disease, months and even years oftentimes being expended in the 
process of destruction of the soft palate and pillars. 

There is also evident an apparently vigorous effort on the part of 
nature to repair the ravages of the disease, in that large bands of 
cicatricial tissue are prominently observable traversing the diseased 
surface. Their contraction serves in a notable degree to enhance the 
distortion to which the morbid process gives rise. 

The diseased action is rarely symmetrical, being usually more 
active on one side than the other. The ultimate result is to produce 
a more or less complete destruction of the soft palate and uvula, while 
the two pillars are rjractically obliterated, and the remains of the 
palate are drawn down and adhere laterally to the posterior wall of 
the pharynx, being drawn to one side or the other, leaving a narrow 
opening into the naso-pharynx. When the posterior wall of the 
pharynx is involved, the destruction of tissue is not so apparent as 
the distortion of the parts. The faucial arch is narrowed by contrac- 
tions, and the smooth surface of the pharyngeal membrane replaced 
by small knob-like projections here and there, marked by small 
points or lines of ulcerative action and traversed here and there by 
bands of connective tissue. 

While the essential lesion in this disease is a tuberculous infiltra- 
tion identical with that which gives rise to tuberculous disease of the 



524 DISEASES OF THE FAUCES. 

lungs, and while it is produced by the same bacillus, the two diseases 
run different courses. As before stated, a certain clinical and patho- 
logical relation is established between lupus and tuberculosis. The 
former disease has been reported by many as a chronic and latent 
form of tuberculosis ; thus, it would seem that lupus bears the same 
relation to chronic tuberculosis as chronic tuberculosis does to the 
acute form. And yet, while both lupus and tuberculosis may be 
coincident in the same individual, no case, so far as I know, has ever 
been observed in which lupus was transformed into an ordinary tuber- 
culous process. Attempts have been made to explain this "latency" 
and "chronicity" of tubercle in lupus on certain anatomical peculiar- 
ities of the skin, but the arguments all fail completely when we trans- 
fer lupus to the mucous membrane of the air tract, a region most 
favorable for the development of a tuberculous process, in that here 
we find it presenting the same latency and chronicity which char- 
acterized its progress in the integument. While, therefore, the 
microscope has revealed the identity of the morbid process and the 
identity of the bacillus in the two diseases, the true explanation of 
the cause of the marked difference in the clinical history has yet to 
be determined. 

The pathological changes which characterize the disease in the 
fauces differ in no essential degree from those already described in 
the chapter on lupus of the nose. 

Symptomatology. — An invasion of the upper air tract by lupus is 
exceedingly insidious, and makes itself manifest at the onset by no 
appreciable subjective symptoms. The later symptoms are generally 
those found in the later stages of tubercular and syphilitic ulceration. 

Diagnosis. — The marked chronicity of the process in lupus, to- 
gether with the unusual form which the ulcerative action takes on, 
with the gross appearance of the disease on ocular inspection form a 
condition which should be mistaken for no other disease. 

The onset of lupus is characterized by an infiltration of the mucous 
membrane by tubercle. This occurs in the form of small nodules, so 
that, in place of a diffuse and uniform thickening of the tissue, we 
have the disease marked by irregular and rounded elevations. This 
may involve at first but a limited area, but, by a slow process of ex- 
tension, it gradually involves, more or less completely, the soft palate, 
faucial pillars, and the pharyngeal wall. On gross inspection, we 
find the membrane presenting this nodulated outline. This is more 
prominent in some places than others, but the smooth contour of 
the mucous surface is completely obliterated wherever the diseased 
process has extended. 

When ulceration sets in, this process occurs only in exceedingly 



LUPUS OF THE FAUCES. 525 

limited areas, and is not usually recognized by any purulent dis- 
charge or yellow ulcerated surface. It occurs in small spots, lines, or 
fissures, and the surface presents a reddish, velvety aspect which can 
only be recognized as a truly ulcerative process by careful inspection. 
Comparatively early after the onset of the attack, the vigorous efforts 
at repair on the part of nature are evidenced by the appearance of 
granulating surfaces, which subsequently are converted into bands of 
connective tissue, forming more or less extensive cicatrices. After 
the disease has persisted for some time, these cicatricial bands, 
traversing the surface of the diseased tissue, become a prominent 
feature on ocular inspection. 

The diseased surface is highly injected, and presents a deep red 
color, of a somewhat sombre and dusky hue, in marked contra- 
distinction from that which attends an acute inflammatory process, 
and yet of a lighter color, as a rule, than that which we meet with in 
syphilitic disease. The mucous membrane surrounding the diseased 
process is usually perfectly normal in aspect, although occasionally 
slightly injected owing to the mechanical interference with the return 
venous circulation by the cicatricial deposit, or in consequence of the 
distortion of the healthy parts as the result of their contractions. 

The disease need not be confounded with tuberculosis, because the 
latter affection is characterized by marked anaemia of the surround- 
ing membrane, with a pale, grayish, ulcerative process, which is dis- 
tinctly and easily recognized as a progressive destruction of tissue. 
A tuberculous ulcer, furthermore, is usually covered by a thick, ropy, 
tenacious mucus or muco-pus, in all these points differing strikingly 
from lupus, in which there is marked hyperemia and almost total 
absence of secretion, while the ulcerated surface is almost identical in 
color with the non-ulcerated parts. Furthermore, the tuberculous 
cachexia is almost invariably present in a marked degree in tubercu- 
lous disease of the upper air passages, while in lupus the general 
health is not affected. 

The only form of syphilis with which it may be confounded is the 
tertiary ulcer. 

In malignant disease we have a well-marked tumor, projecting 
into and encroaching upon the air tract, in contradistinction to the 
somewhat diffuse infiltration of the mucous membrane which char- 
acterizes lupus. 

In either case the patient should be placed under antispecific 
remedies, which in a case of lupus would not only fail to improve the 
aspect of the disease, but in most instances probably would aggravate 
it, and in malignant disease would soon enable us to make the 
diagnosis. 



526 DISEASES OF THE FAUCES. 

Course and Prognosis. — As we have already seen, in the large 
majority of instances lupus of the air passages is secondary to cutane- 
ous lupus. That the faucial disease is to be considered an exceed- 
ingly grave complication of the cutaneous lesion cannot be questioned, 
it involves no little discomfort, impairment of function, and suffering ; 
and yet the prognosis of lupus, whether of the air tract or of the 
integument, is not usually to be regarded as a grave one, for it very 
rarely terminates fatally. Invasion of the air tract, moreover, seems 
to add but little to the gravity of the disease, nor does it ever take 
on renewed activity in these parts, maintaining rather the same great 
chronicity which characterizes its progress as a cutaneous affection. 

While the presence of the disease in the fauces involves merely a 
certain amount of discomfort, with impairment of function, the real 
gravity which attaches to it is the danger of the laryngeal invasion. 
Aside from a case reported by Landrieux, I know of no fatal termina- 
tion from faucial lupus. 

The clinical history of these cases, as in cutaneous lupus, is 
marked by more or less prolonged periods of quiescence, during which 
the disease either ceases to advance or there may even be notable 
improvement. I know of no case of spontaneous cure of faucial 
lupus, although this occasionally occurs in the cutaneous disease. 
In a case reported by Cazin, the lupus of the fauces disappeared 
spontaneously after convalescence from erysipelas. The larynx, 
however, was not involved. 

Treatment. — For convenience, we may divide the measures of 
treatment into topical applications, curetting, excision, internal med- 
ication, and injections of tuberculin. 

Topical Applications. — The various local remedies which have been 
used with more or less success are: Nitrate of silver (one hundred 
and twenty to four hundred and eighty grains to the ounce), tincture 
of iodine, lactic acid (from twenty to eighty per cent solution), solu- 
tion of the perchloride of iron (one hundred and twenty grains to 
the ounce), and the galvano-cautery. 

Bowen reports the case of a male, aged thirty-nine, in which the 
faucial invasion, occurring six years after the cutaneous lesion, was 
cured by the application of a four hundred and eighty-grain solution 
of nitrate of silver, together with the subsequent use of perchloride 
of iron and iodoform. Ziemssen seems to have been equally success- 
ful with the solid stick of nitrate of silver, in a girl aged twelve, in 
whom the disease invaded the larynx primarily, there being no other 
lesion. The affection had lasted a number of years. 

Asch reports the case of a female, aged eighteen, suffering with 
pharyngeal and laryngeal lupus, without cutaneous lesion, which was 



LUPUS OF THE FAUCES. 527 

i 

practically cured in about twenty-two months by local applications of 
a four hundred and eighty -grain solution of nitrate of silver, together 
with the internal administration of five-drop doses of Fowler's solu- 
tion, gradually increased to ten drops. In the latter part of the 
treatment a one hundred and Went y -grain solution of perchloride of 
iron was used, together with the internal administration of cod-liver 
oil. 

Moure recommends the use of chromic acid, fused on the end of a 
slender probe. 

The Curette. — The good results so frequently obtained by curet- 
ting in cutaneous lupus naturally suggest the resort to this measure 
in faucial invasions. Lupus of mucous membranes, however, seems 
to act different^' from the same disease invading the integument 
and I find no records of notable success from this measure in the 
faucial disease. In the single case in which I have observed its use 
in the air tract, it seemed to have done more harm than good. 

Excision. — When the disease is limited and the parts are accessi- 
ble, there can be no question as regards the advisability of the ex- 
cision of the morbid tissue. Browne very properly advises the 
amputation of the uvula when the disease invades this organ pri- 
marily. The same might be stated in regard to the free border of 
the palate or perhaps one of the pillars. The success of this resort 
necessarily depends upon the completeness with which the diseased 
membrane is excised. Hence this measure is probably available only 
when the disease is limited and confined to the soft palate or pillars, 
as its success would be somewhat problematical in the pharyngeal 
wall. Garre reports the case of a woman, aged twenty, in which the 
disease involved the base of the tongue, epiglottis, aryepiglottic 
folds, and arytenoids. It had lasted somewhat over a year. Local 
applications of lactic acid and iodoform were of no avail. Excision 
of the epiglottis also failed to arrest the disease, and he finally per- 
formed subhyoid pharyngotomy and excised all the morbid tissue. 
The procedure seems a somewhat daring one, and yet his success 
seems fully to have warranted it, for at the end of five months there 
was no recurrence of the disease. 

Internal Medication. — Local treatment, of course, should be in all 
cases combined with internal medication. The remedies which seem 
to have given the best results are cod-liver oil, arsenic, and iron. In 
those cases in which the disease has been arrested, it is perhaps 
difficult to estimate whether the favorable result has been due to the 
local applications or to the internal medication. A careful reading 
of cases, however, carries the conviction that internal medication has 
played an exceedingly important part in controlling the diseased 



528 DISEASES OF THE FAUCES. 

action. Whether in the form of arseniate of sodium or in the form 
of Fowler's solution, arsenic certainly seems to possess a somewhat 
specific action in the control of lupus, and our whole duty is prob- 
ably done in no case without fully testing its efficacy. Its action, 
moreover, seems to be aided by the coincident administration of cod- 
liver oil and general tonics according to indications. 

Tuberculin. — In regard to the injection of Koch's lymph for the con- 
trol of lupus, while a number of cases seem to have been temporarily 
improved and the disease apparently arrested perhaps, so far as I 
know, there is no well-authenticated case of lupus, either of the skin 
or air tract, which has been permanently cured by this measure. 
The same should be stated in regard to the cantharidate of potash, 
as advocated by Liebreich. 









CHAPTER LXVIIL 

FOKEIGN BODIES IN THE FAUCES. 

Our main consideration in this chapter is the subject of foreign 
bodies in the pharynx, although occasionally we find small bodies, 
such as pins, needles, fish-bones, etc., lodging in the faucial or lin- 
gual tonsils, and sometimes piercing the soft palate or pillars. 

The pharynx being a large, open, and easily accessible cavity, 
the natural inference would be that not only might the presence of a 
foreign body in this region be easily detected, but also that it might be 
extracted without great difficulty ; and yet it is by no means rare that 
cases of this sort present notable difficulties, not only in directly locating 
the body, but also in devising some successful method for its removal. 

Among the most common objects which lodge in the fauces are 
small fish bones taken in with the food. They are exceedingly liable 
to become embedded in the spongy tissue of the lingual or faucial 
tonsils, where, on account of their color and diminutive size, it is not 
always easy to detect their location. They make their appearance 
known by the prickling pain which occurs with the act of deglutition ; 
and the patients, moreover, find it by no means easy to distinctly 
locate this pain. 

Next in frequency after the lingual we find the small bones em- 
bedded in the faucial tonsil, the pyriform sinuses, the posterior 
pharyngeal wall, or the orifice of the oesophagus. 

The search for them should always be made with the best light, 
sunlight being used if possible; when located, they are easily ex- 
tracted by means of properly curved forceps, using direct or reflected 
light as may be necessary. 

Pins, needles, and sharp objects of that sort form another class 
which make their way frequently into the fauces. 

These small sharp bodies, while giving rise to distressing symp- 
toms at the time, ordinarily involve no grave danger, although deaths 
have been known to occur. 

The^v usually give rise to pain on movement of the pharynx, with 
certain reflex disturbances, such as cough, retching, etc. If they 
remain a sufficientlv long time, they may cause inflammation and 
34 



530 DISEASES OF THE FAUCES. 

suppuration, or, piercing the tissues, they may become encysted. 
Frequently they migrate even without giving rise to any notable 
symptoms, penetrate the tissues of the neck, and finally emerge, with 
or without suppuration, beneath the skin. 

If the object be sufficiently sharp, it may make its way to the 
skin without exciting a suppurative process, although, as the object 
approaches the skin, abscess formation is likely to occur, as in the 
case reported by Thevenot, in which a fish bone, migrating from the 
fauces, gave rise to a subcutaneous abscess extending from the angle 
of the jaw to the chin. Dunbar reports a case of a pin, two and one- 
quarter inches long, remaining embedded in the pharynx eleven 
months, giving rise to pain, cough, expectoration, etc. It was finally 
expelled' voluntarily, in two pieces. 

In a case recently seen by the author, a young girl, holding in 
her mouth a bonnet pin five inches in length, had fallen upon her 
face, driving the pin directly back through the palate, and embedding 
its point in one of the vetebrae. Considerable force was necessary to 
extract it, and yet no unpleasant symptoms followed. 

Grave operative interference is rarely demanded in the case of 
these pins, needles, etc., and yet Wheeler reports an instance of a 
man aged forty-five having swallowed a threaded needle, which was 
lodged in the fauces in such a way that the left posterior palatal fold 
was transfixed while its point was inserted into the left arytenoid. 
It was so firmly fixed in its position that lateral pharyngotomy was 
performed for its removal. 

Living objects in the fauces would seem to be a rare accident, yet 
cases are on record of such occurrences. 

Smooth, rounded bodies, such as coins, medals, buttons, nuts, 
marbles, etc., when they make their way into the fauces, usually pass 
into the oesophagus, lodging at the prominence of the cricoid cartilage, 
or at the lower end of the oesophagus, or they may pass into the 
stomach. When these bodies fail to enter the oesophagus, they are 
usually found projecting from its orifice, or else in the pyriform 
sinuses. The symptoms to which bodies lodged here give rise are 
usually dysphagia, cough, expectoration, and some loss of voice, ac- 
cording as the larynx may be involved, together with certain reflex 
disturbances, such as convulsive movements of the fauces, while in 
young children general convusions may ensue. The interference with 
deglutition necessarily results in impaired nutrition, with loss of flesh. 

The location of a foreign body of this kind is based not only on 
inspection by direct and reflected light, but also on exploration of the 
parts by means of the index finger. If the patient is young, external 
manipulation may be of service ; ordinarily, however, the removal of 



FOREIGN BODIES IN THE FAUCES. 531 

these objects is accomplished with comparative ease by means of a 
properly curved forceps, which is manipulated with the aid of the 
laryngeal mirror, or, better still, I think, as a rule, by means of the 
index finger of the left hand. The administration of an anaesthetic is 
rarely necessary, except in very young children, for, whereas in the 
oesophagus the use of ether or chloroform is necessary in order to 
produce relaxation of muscular spasm, a foreign body in the pharynx 
or mouth of the oesophagus is not ordinarily held with sufficient force 
to interfere with its extraction. When the body can be reached and 
located by means of the index finger, it is comparatively rare that it 
cannot also, with equal facility, be seized and removed by means of 
the forceps. Of course, in exploring the fauces by means of the 
finger, retching and even vomiting is liable to be excited, and the ob- 
ject expelled thereby. This is probably a better method of produc- 
ing emesis than the administration of drugs. 

Impaction of these bodies in the fauces is comparativeh' rare, and 
yet when it does occur it is liable to give rise to inflammation and 
subsequent pus formation. 

We have thus endeavored to group, to a certain extent, the com- 
moner objects which we are called upon to remove from the fauces. 
Any attempt at further classification would be useless, in that the 
number and variety of objects which are met with here are endless. 

The dropping of false teeth into the pharynx during sleep is by 
no means an uncommon .accident, many such case having been re- 
ported. In one it happened during the administration of an anaes- 
thetic, in another as the result of a fall. The symptoms are usually 
pain in the throat and dysphagia, with more or less dyspnoea, accord- 
ing to the size and location of the plate. In a case of Paget' s the plate 
was lodged in the glosso-epiglottic fossa, and was the unrecognized 
cause of pain on swallowing and progressive emaciation for nearly 
four months. In one reported by Carlyle the teeth remained in the 
pharynx ten hours, giving rise to no symptoms other than slight im- 
pairment of phonation. A patient of Pollock's died from suffocation 
immediately upon the occurrence of the accident. I find no other 
fatal case reported, although one patient died after an external pha- 
ryngotomy — an operation which was done also in two of Cock's 
cases, although in most instances the plate is removed with com- 
parative ease by means of the forceps. 

Instances of the swallowing of large and irregular pieces of bone 
taken in the food are exceedingly common, and their presence fre- 
quently constitutes a condition of no little gravity, on account of the 
difficulty of their removal and the dyspnceic symptoms which are 
very liable to occur. 



CHAPTER LXIX. 

NEUKOSES OF THE FAUCES. 

The great activity and diversity of function which characterize 
the parts in the faucial region, naturally demand an unusually rich 
nerve supply. Hence, we expect to find this region the seat of 
numerous disturbances of a neurotic character. As a matter of clini- 
cal observation, however, I am disposed to think that genuine neu- 
roses involving the organs of the fauces are comparatively rare. For 
the present consideration they may be classified as follows : 

1. Abnormalities of sensation. 

2. Neuralgias. 

3. Keflex neuroses. 

4. Spasmodic disturbances or chorea. 

5. Myopathic paralysis. 

6. Bulbar paralysis, or paralyses due to central lesion. 

Abnormalities of Sensation. 

Cohen thinks that both hyperesthesia and anaesthesia may occur 
as independent affections involving the palate as well as the pharynx. 
Paresthesia is described by A. H. Smith, Fr. Knight and others, as 
a perverted sensation of tingling, prickling, or as of a foreign body 
in the fauces. These cases, however, in the large majority of in- 
stances are due to the presence of enlarged glands in the glosso-epi- 
glottic fossa?, to distended tonsillar crypts, or to some other local 
organic change. 

In my own experience, I have seen no case in which the local 
conditions were such as to demand topical remedies. The condition 
is one which must be corrected by the administration of general 
tonics. 

Neuralgia. 

A sore throat with little if any inflammatory lesion is a matter of 
frequent observation. Moreover, it is exceedingly difficult, often- 
times, to definitely locate the source of a painful symptom referable 



NEUROSES OF THE FAUCES. 533 

to the fauces. Many of these cases, therefore, we are compelled to 
classify as neuralgic. They usually occur in nervous and hysterical 
women, and are simply local manifestations of a general condition. 
In other cases we frequently meet with neuralgic pains in connection 
with chronic follicular pharyngitis, as has been already observed in 
the discussion of that affection. This is particularly true in connec- 
tion with pharyngitis lateralis. 

The source of the pain is probably either in the terminal fila- 
ments, or small branches of the glosso-pharyngeal, and here also the 
indications for treatment are the administration of iron, quinine, and 
general tonics for the correction of the systemic condition. Topical 
remedies are of no avail. It is of the utmost importance, however, 
to thoroughly investigate the condition of both the lower and upper 
pharynx, together with the tonsils and the glands at the base of the 
tongue, for I am confident that many cases of faucial pain may be 
traced to a morbid condition of some of the lymphatic bodies in this 
region, such as the faucial and lingual tonsil, etc. , or the existence of 
imprisoned secretions, or some other local cause. I do not think 
that local lesions give rise to neuralgia, except when the general 
system also is at fault. The internal administration of quinine, iron, 
general tonics, etc., is therefore probably indicated in every case. 

Eeflex Neuroses. 

Various reflex disturbances, due to the presence of enlarged ton- 
sils, are frequently reported, such as cough, aural pain, nightmare, 
gastric disorders, etc. I do not think these should be regarded as 
purely reflex disturbances, for they are oftentimes symptomatic of 
the tonsillar disease. In the same category the pharyngeal irritation 
described by Harrison Allen may be placed. I see no reason why 
cough may not be directly symptomatic of pharyngeal disease. 

Spasmodic Disturbances, or Chorea. 

Abnormal muscular contractions, as involving the faucial region, 
are largely confined to the soft palate, and as a rule assume that 
peculiar character which from a clinical point of view is generally 
described under the designation of chorea, although the cases re- 
ported are usually defined as instances of clonic spasm of the palate, 
the term chorea not being used. 

In the large majority of cases, the muscle which seems to be 
mainly involved is the levator palati ; the soft palate is rapidly drawn 
up against the pharyngeal wall, and again released, and this move- 



534 DISEASES OF THE FAUCES. 

ment is repeated a number of times until the clonic spasm of the 
levator muscle ceases. Each contraction is accompanied by a curious 
clicking sound in the ear, which is noticed not only by the patient 
but by one standing near, which probably arises as the soft palate 
detaches itself from the pharynx after each contraction. The move- 
ments during their progress are of a somewhat rhythmic character, 
which is not only appreciated by the patient, but can be easily ob- 
served by ocular inspection of the fauces. 

Tonic spasm of the palatal muscles proper never occurs, so far as 
I know, although Wagner states that in advanced stages of paralysis 
agitans movements of the soft palate may occur very similar to those 
of the muscles of the trunk or extremities. Spencer reports two cases 
of clonic spasm of the constrictor muscles of the pharynx, in which 
there were also similar movements of the eyeball, as well as of the 
arytenoid cartilages. These movements, moreover, were synchronous 
in all of the parts involved. The origin of the disease here was in a 
cerebral tumor. 

In the cases in which the levator palati muscle alone was involved, 
the origin of the disease seemed to be quite as obscure as in instances 
of general chorea, and in most cases it is impossible to assign a 
definite cause to the occurrence of the disorder. 

The prominent indication for treatment consists in the removal of 
any possible source of reflex disturbance, such as intranasal or 
pharyngeal disorders. We possess no drug which exercises a spe- 
cific influence on choreic affections. Probably our most efficient 
remedy lies in the administration of some preparation of arsenic, in 
connection with general tonics and iron. In addition to this, of 
course, a certain amount of attention should be directed to the regula- 
tion of the diet, clothing, outdoor exercise, bathing, etc. 

Myopathic Paralysis. 

This term is one which has come into somewhat general use as 
describing a form of paralysis which is confined to individual mus- 
cles or groups of muscles. The name would seem to suggest that 
the true lesion lies in some morbid condition of the muscular fibres 
rather than in any defective innervation. This view is doubtless an 
error, in that the true pathological condition is probably some abnor- 
mality in the smaller nerve trunks or terminal fibres ; and yet, the 
term "myopathic paralysis" being one of such general use, I do not 
feel at liberty to discard it. 

As affecting the faucial region, we may have a paralysis involving 
a portion or all of the muscles which act upon the soft palate. The 



NEUROSES OF THE FAUCES. 535 

paralysis may be unilateral or bilateral ; or we may have it complete 
on one side and incomplete on the other, viz., a paralysis of one half 
of the palate with paresis of the other half. 

It is often assumed that the occurrence of paralysis in the palate of 
a child is sufficient evidence of the diphtheritic character of a previ- 
ously existing faucial inflammation. I think this view must be 
abandoned, and that we must accept not only the teaching that a 
myopathic paralysis may follow any form of inflammatory lesion in 
the fauces, but also that it may occur without any previously existing 
local affection. If we accept this view, it necessarily follows that the 
cause of these local paralyses is not in a localized lesion, but in a 
general blood condition. 

In those cases in which the palate is paralyzed, the symptoms have 
reference mainly to the loss of function of this organ. Deglutition 
is somewhat impaired, and the food has a tendency to make its way 
into the nasal cavity. This is especially true of fluids. The promi- 
nent symptom, however, has reference to the voice, which is thick 
and decidedly nasal in character ; articulation is exceedingly difficult, 
phonatory waves escaping into the nasal cavity. Whistling and 
puffing out the cheeks are impossible. Expectoration also is notably 
hampered; consequently there is a tendency to accumulation of 
mucus in the faucus, which the patient is unable to expel. These 
symptoms are quite marked when both sides of the palate are para- 
lyzed. Occasionally, however, the paralysis is confined to one side, 
in which case, of course, the symptoms are somewhat modified. 

An inspection of the parts easily reveals the condition. The pal- 
ate and uvula hang down motionless and fail to respond to ordinary 
stimuli, such as the probe, etc. If one side only is involved, the 
uvula is notably drawn to the healthy side, while the pillar of the 
fauces and whole palate seem to be drawn down by the action of the 
palato-glossus and palato-pharyngeus muscles. 

We occasionlly see cases, usually in adult life, in which there is a 
markedly paretic condition of the muscles of the fauces, mainly 
noticeable in the impairment of the act of deglutition. The bolus of 
food, reaching the pharyngeal cavity, is not seized with sufficient 
vigor to propel it into the oesophagus, nor can it be expelled into the 
mouth with ease. The result is an attack of choking, which is often- 
times a source of great distress to the patient, although rarely dan- 
gerous. In a series of cases of this sort reported by the writer, the 
symptoms simulated, in no small degree, that of stricture of the 
oesophagus. The diagnosis was based on the fact that the constrictor 
muscles of the pharynx responded very sluggishly to the impact of 
the probe, and, furthermore, sensibility was diminished, as decided 



536 DISEASES OF THE FAUCES. 

by the sesthesiometer. The disease occurred in individuals of im- 
paired general health, and disappeared under the administration of 
general tonics, such as chalybeates and strychnine, and the applica- 
tion of the farad ic current. 

Practically, the same indications are present in the cases of com- 
plete paralysis following diphtheria and other diseases. 

The faradic current here, I think, aids materially in hastening the 
cure of the disease, and should be administered by applying tho 
sponge electrode to the back of the neck, while a small-pointed 
metallic electrode is pressed upon the faucial muscles consecutively. 

The prognosis is always good in cases of so-called myopathic 
paralysis, although complete restoration may be delayed for weeks 
and even months, especially after severe cases of diphtheria. 

Paralysis Due to Bulbar Lesion. 

Under this heading we consider those forms of paralysis which 
are the result of a diseased condition of the medulla oblongata. This 
as we know, is not only an organ of nerve conduction, but it also 
contains within it nuclei which act as nerve centres, presiding over 
certain vital phenomena, such as respiration, cardiac inhibition, 
vasomotor control, deglutition, etc. 

In the present consideration of faucial paralyses, we have to do 
mainly with the functions of articulation and deglutition. 

Excluding those cases which we have already designated as myo- 
pathic paralyses, all cases of paralysis of muscles of the fauces must 
probably be traced to some central lesion in the medulla, with the 
exception of instances of paralysis of the levator palati and azygos 
uvulae muscles, which derive their innervation from the facial. These 
latter muscles, therefore, may be the seat of a paralysis as the result 
of pressure on the nerve trunk. This is especially liable to occur 
where the facial nerve passes through the aquaeductus Fallopii. 

The lesions which may give rise to paralysis in the fauces are 
acute and chronic bulbar myelitis, hemorrhage, embolism, tumors, 
and basilar meningitis. 

Up to comparatively recent times, all forms of paralysis due to 
disease of the medulla were described under the head of " progressive 
bulbar paralysis," indicating an essentially chronic affection. Later 
investigations have shown the existence of a similar disease running 
an acute course, while still later study has shown that embolism, 
apoplexy, and tumors in the medulla may be the source of the pecu- 
liar train of symptoms which characterizes bulbar disease. 

Acute Bulbar Paralysis, or Acute Bulbar Myelitis.— This 



NEUROSES OF THE FAUCES. 537 

form of paralysis running an acute course is an exceedingly rare 
event. Our attention was first called to it by Leyden, who reported 
in detail the clinical histories and results of autopsies in three cases 
which occurred respectively at the ages of thirty-six, fifty-two, and 
sixty -two, and terminated fatally at the end of from four to ten days. 
There were two females and one male. 

The characteristic symptoms of the acute form of the disease are 
the suddeness of the invasion and the rapidity with which the paral- 
ysis develops. The patient is seized with headache, giddiness, and 
perhaps vomiting, together with general weakness and unsteadiness 
of gait. There is no loss of consciousness. The dysphagia in- 
creases, and articulation becomes thick and difficult. The move- 
ments of the tongue and lips show evidence of the progressive 
involvement of the bulbar nuclei which preside over the functions 
of articulation, respiration, and cardiac inhibition. The pulse also 
becomes small, rapid, and intermittent, and a fatal termination soon 
follows. Treatment is of little avail. 

Chronic Bulbar Paralysis, or Chronic Bulbar Myelitis. — This 
affection was first described by Duchenne as a separate disease, under 
the name of "progressive muscular paralysis of the tongue, soft 
palate, and lips," although isolated instances of this affection had 
previously been reported by Bell, Trousseau, and Dumesnil. While 
Duchenne gives an admirable clinical description of the disease, its 
true pathological character remained obscure until Wachsmuth stated 
that the cause of the disease would be found in a morbid lesion of 
the medulla, and hence suggested that the disease be called "pro- 
gressive bulbar paralysis." Later investigation not only confirmed 
Wachsmuth's theoretical suggestion, but also revealed the fact that 
the starting-point of the disease lay in certain degenerative changes 
in the bulbar nuclei, which led Kussmaul to propose the name of 
"progressive bulbo-nuclear paralysis." 

We can assign no cause for the disease. That most frequently 
suggested is exposure to cold. It occurs more often in men than 
in women, and is essentially a disease of later life, occurring usually 
after the fourth decade. 

The onset of the disease is ordinarily quite insidious, the first 
symptoms being a slight sensation of uneasiness in the back of the 
neck, with perhaps a little hesitancy of speech or articulation. This 
is soon followed by a slight difficulty in deglutition. In connection 
with this there is a certain diminution of reflex irritability of the 
mucous membrane of the pharynx. The impairment of deglutition 
is due primarily to paralysis of the palate, which also notably affects 
the vocal tones, giving rise to a nasal twang, with imperfect articula- 



538 DISEASES OF THE FAUCES. 

tion. Mastication is soon affected, mainly owing to the defective 
movements of the tongue in managing the bolus of food. 

As a rule, the laryngeal symptoms are not very prominent. This 
seems a rather curious feature of the disease, and one not easily 
accounted for. In my own experience, in unilateral bulbar disease 
due to embolism, endarteritis, etc., when the larynx has been in- 
volved, it is usually a paralysis of abduction that is noticed. If the 
same rule obtained in Duchenne's disease, a bilateral paralysis of 
abduction would give rise to notable and distressing symptoms of 
dyspnoea, with recurrent attacks of spasm of the glottis. Again, 
when tabes has invaded the medulla, clinical experience teaches us 
that it is very liable to give rise to what has been termed laryngeal 
crises, which are due most frequently to bilateral paralysis of the 
abductors. Why this should not be more liable to occur in pro- 
gressive bulbar paralysis, at first seems somewhat puzzling. Gowers 
states that, whereas paresis of the laryngeal muscles is quite com- 
mon, " laryngeal palsy rarely becomes complete, and it is still rarer 
for the power of abduction to be specially lost." As we have already 
seen, the nucleus of the accessory nerve is invaded somewhat late in 
the disease. Hence, the fact that complete abductor paralysis does 
not occur can only be explained by the fact that death ensues before 
the sclerosis has fully destroyed the nuclei of the accessory nerve. 
Why these nuclei are so frequently destroyed in tabes and not in 
Duchenne's disease cannot be fully explained. 

The prognosis in these cases is an exceedingly grave one, and 
death usually occurs in from one to five years after the manifestation 
of the first symptoms, no case of recovery having been recorded. 
Furthermore, the course of the disease is steadily progressive, any 
temporary arrest or amelioration of symptoms being an exceedingly 
rare event, the cause of death being either general inanition, or 
dyspnoea or heart failure. 

Sudden ok Apoplectiform Bulbar Paralysis. — This term is used 
to describe those cases of bulbar paralysis which, while coming on 
suddenly, are attended oftentimes with somewhat obscure and puz- 
zling symptoms at the onset, and which therefore not infrequently 
present certain diagnostic difficulties. The term is used as a purely 
clinical one, for the reason that, while the train of symptoms which 
these cases present is very similar in character, the pathological 
lesions vary in different instances. 

This is the form of bulbar paralysis, moreover, which is of special 
interest to the laryngologist, as the diagnosis must in a very large 
degree be based upon an inspection of the fauces. The recognition 
of the special bulbar lesion, however, is at best but a matter of opin- 



NEUROSES OF THE FAUCES. 539 

ion based on a careful analysis of local and general symptoms, and 
as a rule is only clearly demonstrated upon a post-mortem examina- 
tion. 

We therefore include under this head cases of bulbar paralysis 
which are due to hemorrhage, embolism, endarteritis, softening, etc. 

A prominent point for discussion, of course, in connection with 
this disease is the question of diagnosis. This is necessarily based 
on the existence of a paralysis coming on suddenly and involving 
muscular structures which receive their innervation from the ganglia 
which are located in the floor of the fourth ventricle. This paralysis 
may be unilateral or bilateral, depending upon the involvement of 
one or both sides of the bulb. It may confine itself to half the pal- 
ate, as in a unique case reported by Dumesnil, or it may involve the 
movements of the larynx, pharynx, palate, and tongue, which are 
governed by the bulbar ganglia. 

The attack comes on suddenly, and usualty during sleeping hours. 
The patient awakens in the morning with a feeling of malaise, indis- 
position to move, dizziness, and perhaps headache, with vomiting; 
but his attention is first called to a condition of paralysis usually in 
the attempt to swallow, which is found to be either difficult or im- 
possible. While there is no paralysis of the muscles of the extremi- 
ties, their movements are, at the onset of an attack, very liable to be 
affected, probably as the result of some disturbance of the circulation 
in the anterior pyramids. This symptom, however, usually passes 
away after a time. If the muscles of the larynx are affected, the 
paralysis is usually complete of one or both sides, although a number 
of instances of simple abductor paralysis have been reported. 

The extent of paralysis in this region can be determined only by 
laryngoscopic examination. 

Paralysis of the palate and pharynx is usually made out on in- 
spection of the parts and by stimulation with the probe. Unilateral 
paralysis is indicated by the drawing of the palate and uvula, with 
protrusion of the tongue, to the paralyzed side. Pain, with feeling 
of stiffness, perhaps, in the region of the nucha, while not a constant 
symptom, is not infrequently present at the commencement of the 
attack. 

To clearly localize a lesion in the medulla, as the source of paral- 
ysis of faucial muscles, will not infrequently present a problem of 
some difficulty ; and yet I am disposed to think that in the majority 
of cases the apoplectiform character of the attack, without loss of 
consciousness, the general motor disturbance, together with a careful 
analysis and study of the area of the paralytic invasion, will serve in 
most instances to make the diagnosis comparatively clear; certainly 



540 DISEASES OF THE FAUCES. 

a coincident invasion of the muscles of the tongue and pharynx, or 
of the muscles of the palate and larynx, would indicate a bulbar 
lesion. 

The difficulty of diagnosis occurs in those exceedingly rare in- 
stances in which the paralytic area is but small in extent. 

The prognosis of these cases is usually not essentially grave, in 
that the disease is not a progressive one, the whole mischief having 
been accomplished with the first seizure. In rare instances, however, 
an endarteritis, perhaps, or some other lesion, may set up changes 
which become progressive, and the disease may go on to a fatal 
termination. 

The treatment of the affection, of course, is purely a treatment of 
symptoms. The measures to be pursued have already been suffi- 
ciently indicated in the discussion on the treatment of progressive 
bulbar paralysis. 

Bulbar Paralysis Due to the Presence of Tumors, Menin- 
gitis, etc. — Cases in which faucial paralysis is the result of tumors 
in the medulla are exceedingly rare. When this occurs, however, it 
is not ordinarily a difficult matter to locate the lesion in the bulb, 
although, of course, the recognition of the special form of neoplasm 
is usually only determined by a post-mortem examination. 

The symptoms develop somewhat slowly, and consist usually of 
some disturbance of vision, with perhaps dilatation of the pupils. 
There is headache and nausea, with motor and sensory disturbances 
in the fauces and perhaps other parts, dependent upon the size and 
location of the growth. 

In a case reported by Joh. Erichsen, in connection with certain 
general symptoms there was paresis of the right side of the palate, 
loss of voice, and anaesthesia of the right side of the face, which an 
autopsy revealed to be the result of a tuberculous tumor in the 
floor of the fourth ventricle, the size of an almond, which covered 
the right half of the bulb, completely destroying the right restiform 
body. 

In a case reported by Sokaloff, there was weakness of the right 
arm and leg, defective hearing, right facial paralysis, difficulty in 
deglutition, deviation of the tongue and uvula to the right, and paral- 
ysis of the left vocal cord. Dyspnoea occurred later in the disease. 
The autopsy revealed a glioma involving the left side of the pons, 
medulla, and olivary body. 

McBride reports a case in which a carcinoma of the base of the 
skull gave rise to paralytic symptoms involving the hypoglossal and 
glosso-pharyngeal nerves of the left side, left abductor paralysis, and 
complete anaesthesia of the left half of the larynx. 



NEUROSES OF THE FAUCES. 541 

Turner reports a case of a child, aged five, that suffered from 
difficulty in deglutition and from cough, together with unilateral 
atrophy of the tongue and paralysis of the soft palate and of the 
laryngeal muscles. There was also atrophy of the optic nerves, and 
a weakness and atrophy of the right arm. The history of hereditary 
syphilis in this case led to a diagnosis of syphilitic disease of the 
basilar meninges. 

In a case reported by Nothnagel, an abscess, originating in the 
petrous portion of the temporal bone, gave rise to paralysis and 
atrophy of the left side of the palate, anaesthesia of the left half of 
the larynx, abductor paralysis of the left vocal cord, dysphagia, and 
paresis over the distribution of the left facial, abducens, and trigem- 
inus nerves. 

We have thus discussed the question of paralysis, as involving the 
muscular structures of the fauces, due to the various forms of bulbar 
disease, confining our attention largely to the local paralytic mani- 
festations, although it must be borne in mind that in many of the 
morbid conditions alluded to, and in many of the cases reported, 
other and prominent symptoms have not been fully discussed, in that 
our main interest here has to do with those cases which present to 
the throat specialist. In this connection we should bear in mind 
that in many instances an ordinary case of facial paralysis, due to 
pressure on the nerve trunk as it passes through the aquaeductus 
Fallopii, is attended with paralysis of the levator palati and azygos 
uvulae muscles of the same side, as observed by Dumesnil and Sanders. 
This form of palatal paralysis, however, gives rise to no prominent 
symptoms and is usually overlooked on account of the more evident 
pathological condition of the facial muscles. The paralysis of the 
palate, complicating disease of the mastoid, as in the case reported 
by Gairdner, arose in the same way, in connection with facial 
paralysis. 

Sanders reports a case of palatal paralysis, complicating diabetes, 
which is of special interest in connection with the supposed location 
of the diabetic centre in the floor of the fourth ventricle. 

Herpes of the Fauces. 

This affection consists in the development in the mucous mem- 
brane of the faucial region of an eruption presenting all the appear- 
ances of true herpes. It is, moreover, attended with certain symp- 
toms, both local and constitutional, which render it analogous with 
herpetic eruptions on the skin. In an exceptionally large experience 
in throat diseases I have met with onlv a dozen cases which I was 



542 DISEASES OF THE FAUCES. 

*. 
disposed to regard as instances of true herpes, although Chapman 
states that in an experience of six years he has recorded over a hun- 
dred cases. 

In three of the cases which I have seen the eruption showed itself 
in the form of herpes iris; that is, there were developed in the 
mucous membrane small rings of minute papules, partially or com- 
pletely enclosing a patch of health}' membrane. In another case the 
small papules seemed to arrange themselves somewhat irregularly in 
the mucous membrane of one side of the fauces. In another case 
they formed a line along the junction of the hard and soft palate. 
These papules manifested no tendency to develop into vesicles, but 
consisted in minute red points in which the membrane was very 
slightly raised above the surface. 

As to what special condition gives rise to the eruption I am some- 
what uncertain, but I am disposed to regard it as a localized inflam- 
mation of the papillae of the subepithelial layer of the mucous 
membrane originating principally in the terminal filaments of the 
nerves. 

The eruption in all the cases that I have seen has been on the soft 
palate and uvula, and furthermore it has always been confined to one 
side. The eruption was not usually a continuous one, but the patches 
would make their appearance, and after a period of from five to ten 
days would disappear, and recur again after an interval of perhaps a 
week, or even longer, sometimes remaining absent for months. The 
same was true of the individual papules ; each showed a tendency to 
come and go independently of its fellows. 

The prominent symptoms to which this eruption gives rise are 
more or less pain referable to the faucial region, constant and some- 
what annoying in character, and increased by deglutition. There is 
a general sense of discomfort about the throat, attended oftentimes 
with a most intolerable itching about the parts. The minute spots 
or papules stand out prominently as to color, showing a deep pur- 
plish red, in contrast with the pinkish tinge of the healthy membrane 
surrounding them. They occur on one side of the throat, and are 
either scattered irregularly or arrange themselves in the form of 
rings or circles. 

I regard the affection as largely a constitutional one, and hence 
its successful management depends mainly on the internal adminis- 
tration of remedies. 

The treatment from which I have obtained the best results has 
consisted in the administration of cod-liver oil with barks and iron, 
in connection with arsenic. These should be given for a considerable 
length of time until the general health seems fully restored. In 



NEUEOSES OF THE FAUCES. 543 

addition to this, certain local remedies may be used, in order to give 
relief to pain and the intolerable itching to which the affection gives 
rise. For this purpose I have generally found the best relief 
from a gargle composed of ten grains of carbolic acid in an ounce 
of water. 



CHAPTER LXX. 
BENIGN TUMOBS OF THE FAUCES. 

The faucial region does not seem to afford a favorable site for the 
development of benign neoplasms ; and since medical literature fur- 
nishes but a comparatively few reported cases, I have confined my 
consideration of this subject mainly to a brief resume and analysis of 
the cases which I have consulted. 

Tumors of the Soft Palate, Uvula, and Pillars of the Fauces. 

Papilloma. — By far the most common form of neoplasm met with 
in this region is the papilloma which ordinarily attaches itself to the 
tip of the uvula or to the edges of the soft palate or faucial pillars. 
These little warty growths ma>j develop without giving rise to any 
symptoms whatever. In the past few years in my own private prac- 
tice, I have removed a number. These have been small warty 
growths, which showed no disposition to extend and presented no in- 
dications for operative interference. Occasionally the growths show 
a tendency to extend somewhat rapidly and to attain considerable 
size. They seem to arise spontaneously and from no apparent cause. 
Their favorite site is on the edge of the soft palate and uvula, all of 
these being parts which are subjected to notable activity of functional 
movement. Especially is this true of the uvula, in which the largest 
growths have developed. When small in size, they give rise to no 
symptoms ; as they increase in proportions they seem to cause some 
little irritation of the parts, with cough and slight expectoration, but 
mainly a mere sense of uneasiness or irritation ; although cough has 
in some cases been a prominent symptom. The tumor was of such 
length in one case that it projected into the fauces, exciting nausea 
and vomiting, especially after eating; while another is reported of 
a papilloma of the soft palate in a boy aged nineteen, who was the 
subject of convulsive attacks of a hystero-epileptic character when in 
a recumbent position. These disappeared completely upon the re- 
moval of the growth. 

These neoplasms present the ordinary appearances of a papillo- 



BENIGN TUMORS OF THE FAUCES. 545 

matous growth met with in other portions of the mucous membrane, 
viz., a soft, white, mammillatecl appearance with the outlines which 
we recognize as characteristic of this form of growth, a sort of cauli- 
flower or proliferating contour. If there is any question of diagnosis, 
the microscope will reveal the characteristic structure of papilloma. 

The treatment consists in the removal of the neoplasm by means 
of the scissors or snare, cutting not only through its attachment, but 
somewhat into the mucous membrane in order to obviate any ten- 
dency to recurrence, and at the same time to avoid hemorrhage, which 
is far more troublesome when the warty growth itself is cut through 
than when the larger vessels at its base are severed. Ordinarily, 
there is no necessity for cauterizing the base, since if the growth is 
thoroughly extirpated there is no tendency to recurrence. 

Febkoma. — Only seven instances are reported in medical literature 
of a fibrous tumor developing in this region. As occurring in the 
soft palate, these tumors present no notable difference from the same 
variety of growth in other portions of the body. They develop some- 
what rapidly, and give rise to no local symptoms other than those 
which are adventitious and mechanical. Their removal seems to be 
attended with no especial dangers when the operation is undertaken 
sufficiently early. 

Angioma. — Cases of this form of neoplasm have been reported by 
several observers. 

It is difficult to assign any cause for these growths, although 
Ellerman suggests that they may have their primary origin in a 
papilloma which becomes transformed into an angioma as the result 
of negative pressure in the act of deglutition. They are composed 
almost entirely of a network of blood-vessels bound together by a 
delicate connective tissue. The walls of the blood-vessels are exceed- 
ingly thin, also the outer investment of the tumor ; hence, their sur- 
face is very sensitive, and their presence gives rise to more or less 
pain in deglutition, with faucial irritation. 

The diagnosis is easily made on inspection. 

The only indications for treatment consist in the radical removal 
of the growth ; and, considering its vascular character and the trouble- 
some hemorrhage which may attend the operation, the galvano- 
cautery loop would seem to afford the safest method of complete 
extirpation, with the avoidance of troublesome complications in the 
way of hemorrhage. In Leonard's case the angioma apparently in- 
vaded both the hard and soft palate, giving rise to a tumor which 
nearly completely filled the mouth. In the removal of this the 
hemorrhage became so excessive as to render it necessary to abandon 
the primary operation, the wound being plugged for three days before 
35 



540 DISEASES OF THE FAUCES. 

this was resumed, after which the growth was removed by means of 
the ligature. 

In all the cases recorded, the operation has been successful and 
no recurrence has been reported. 

Adenoma. — This form of neoplasm is of comparatively frequent 
occurrence in the palate — a fact whicli may probably be explained by 
the large number of muciparous glands with which the mucous mem- 
brane of this region is endowed. 

In the same category we may place fibro-adenoma for the reason 
that from a clinical standpoint the disease follows the same course 
essentially as that of adenoma. The same can be said of adeno- 
enchondroma. 

Etiology. — We can assign no cause for the development of these 
tumors, and can only say that the disease seems to belong essentially 
to adult life, occurring in most instances between the ages of twenty 
and fifty. It occurs more frequently among females than males, in 
the proportion of about two to one. 

Symptomatology. — These growths develop somewhat slowly, and 
cause no notable symptoms until they have attained such size as to 
interfere with the normal function of the parts. The first symptom 
to which they give rise is merely that of fulness in the throat, and 
possibly some interference with the act of deglutition. Pain is occa- 
sionally present, due perhaps to pressure on the terminal filaments of 
the nerve. The voice is affected according to the size of the neo- 
plasm. If the tumor develop upon the posterior surface of the pal- 
ate, nasal respiration is interfered with. In one case hemorrhage 
also seemed to be a notable symptom, due probably to an erosion of 
the turbinated tissues by the pressure of the growth. Respiration 
may be interfered with if the tumor project backward into the fauces 
in such manner as to obstruct the entrance of air into the larynx. 

These growths are usually sessile in form and contract no adhesion 
to the mucous membrane, but in one case the growth was somewhat 
pedunculated. The surface of the tumor ordinarily shows no ten- 
dency to morbid changes, and is not usually even eroded by contact 
with neighboring parts, although in a case reported the surface of the 
growth was deeply ulcerated. 

Pathology. — Adenomata of the mucous membrane usually have 
their starting-point in certain hypertrophic changes setting in in the 
normal glandular structures of the part in which they arise. The 
soft palate being very richly endowed with lymphatics, we naturally 
find an adenoma of this region containing a considerable amount of 
this tissue. The framework of the tumor is made up of a delicate 
stroma of connective tissue supporting a large number of acini. The 



BENIGN TUMORS OF THE FAUCES. 547 

spaces between these acini are filled in with lymphatic tissue, the 
proportion of gland tissue and lymphatic tissue varying in individual 
cases. According to Deluce the origin of the growth is primarily in 
an obstruction of the orifice of one of the muciparous glands, result- 
ing in dilatation. This is followed by certain morbid changes, in 
which hypertrophy of the gland structures becomes a prominent 
feature. 

Diagnosis. — The main difficulty which is met with in the recog- 
nition of these tumors is in the differential diagnosis between an 
adenoma and fibroma. We are aided somewhat here by the clinical 
history of the case, as a fibroma develops somewhat rapidly, interferes 
more notably with function, and is usually more painful. As regards 
the outline of the growth and its density, there is very little differ- 
ence between the two varieties of neoplasm. They are hard, dense, 
and resisting to the touch, and irregularly rounded in outline. More- 
over, we must remember that, whereas a fibroma is an exceedingly 
rare disease, an adenoma is one of the most common forms of neo- 
plasm met with in the soft palate ; that the adenoma is more frequent 
among females than males ; and that adenoma is usually met with 
between twenty -five and fifty, whereas the fibroid belongs usually to 
an earlier decade. 

Prognosis. — This form of growth possesses no grave symptoms, 
and I find no fatal case of this disease recorded. 

Treatment. — The only indication for treatment is in the removal 
of the neoplasm by surgical interference. This consists in cutting 
down upon the growth and enucleating it. If the growth is large, it 
is better to make an elliptical incision, in order to provide against 
any redundancy of the mucous membrane that might be left after the 
extirpation of the growth. The operation usually is attended with no 
special dangers, although in one case, in the course of the operation, 
it became necessary to ligate, first, the common carotid, and subse- 
quently the internal and external carotids, together with the superior 
thyroid artery. It is interesting to note, in connection with this 
case, that, although the complications interfered with the successful 
extirpation of the growth, it subsequently atrophied, probably as the 
result of the ligation of the arteries. Of course these operations are 
usually done under the administration of anaesthetics, although 
Tillaux removed an adenoma from the posterior surface of the palate 
after applying cocaine. In a case of Dobson's, the tumor projected 
so far into the cervical region as to necessitate external incision. 

Dermoid Tumors. — Tumors of this character are to be regarded 
merely as developmental abnormalities, and do not belong especially 
to any particular tissue or region of the body. 



548 DISEASES OF THE FAUCES. 

A large proportion of these cases have been discovered in post- 
mortem examinations of abortions or premature births. It would 
seem that those cases which have been observed in foetal life were 
extensive in character and did not belong especially to any region of 
the fauces, but really involved quite general attachments. This, 
perhaps, is to be explained by the fact that where the growth is so 
extensive the result necessarily will be the death of the foetus in utero. 
In many of these cases the faucial tumor occurred in connection with 
other deformities, such as cleft palate, club foot, etc. 

In a somewhat exhaustive study of this subject by Arnold, a com- 
pilation is made of thirty-eight cases of dermoid tumors involving 
the fauces. Seventeen of these were instances of premature delivery, 
the child being born dead, while quite a large proportion of the re- 
mainder died at birth or a few days later. 

The origin of this form of tumor is in all cases to be found in 
some error of development during foetal life. 

The growth is always pedunculated, its outer investment being 
formed of ordinary integument, containing hair follicles, sebaceous 
and sweat glands. Its internal contents are made up mainly of fat, 
with muscular tissue, cartilaginous plates, and occasionally osseous 
tissue scattered here and there. 

The symptoms to which they give rise are purely mechanical, in 
that they cause merely a certain amount of interference with the nor- 
mal functions of the parts in deglutition and respiration. They 
should be removed with scissors and they show no tendency to 
recurrence. 

Calcareous Degeneration, or Palatoliths. — Anselmier reports 
two very curious cases of this affection involving the soft palate. In 
one case a boy aged sixteen presented with a history of difficulty of 
deglutition and respiration which had lasted a considerable time. 
He found two masses on the soft palate, one on either side of the 
uvula, about the size of a hazelnut, which on probing through the 
dilated mouths of the palatine glands he found to be calcareous. He 
inserted a tampon saturated with dilute sulphuric acid into these 
recesses, with the result of the complete dissipation of the calcareous 
masses. His other case occurred in a man aged twenty -five, in whom 
he observed three of these masses. The same treatment was success- 
ful in this case. Paget, in commenting on these cases, suggests that 
these formations occurred in the palatine glands and were analogous 
to salivary calculi. 



BENIGN TUMORS OF THE FAUCES. 549 



Tumors of the Tonsil. 

As the tonsil is formed in foetal life by the meeting of the hypo- 
blast, coming up from the intestinal tract, and the epiblast, pouching 
in through the oral cavity, it is the meeting-point of two forms of 
embryonic tissue, and theoretically should afford an exceedingly 
favorable site for the development of neoplastic growths. Clinical 
experience, however, teaches us that benign neoplasms are compara- 
tively rare in the tonsils. The explanation of this undoubtedly lies 
in the fact that the activity of morbid processes in the tonsil belongs 
to the earlier period of life, and, furthermore, that in adult life the 
lymphatic tissue which composes these organs undergoes certain 
retrograde changes in the nature of an atrophy, as the result of which 
they either completely disappear or become masses of inert tissue. 

Fibroma. — Considering the character of the tissue and its activit3 r 
in early life, we might perhaps conclude that it would naturally 
afford a favorable locality for the development of connective-tissue 
growths; and as a matter of clinical observation we find that many of 
the tumors which occur in this locality are fibro-plastic in character. 

Their principal interest lies in the recognition of their clinical 
significance, for they very rarely give rise to any dangerous symp- 
toms, and in no instance has a fatal issue even threatened; unless 
perhaps we except a case of Leffert's, in which the tumor attained 
to such a size as to render the patient's condition somewhat critical 
on account of the danger of suffocation. 

They develop quite insidiously and, as a rule, grow very slowly. 
The presence of the growth in the tonsil seems to give rise to no 
symptoms whatever, and it is only when it has attained such propor- 
tions as to interfere with the functions of the fauces that the patient 
usually becomes conscious of its existence. The first effect of its 
presence seems to be in its interference with the free movements of 
the muscles of the fauces in deglutition, and latterly it opposes itself 
as a mechanical obstacle to the passage of the food. When it is 
pedunculated and freely movable, the growth may fall down over the 
entrance to the larynx and interfere with the respiratory movements, 
although no instance is reported in which the dyspnoea has been of a 
serious nature. 

The recognition of the growth should be comparatively easy, as 
there are few tumors that present so characteristic an appearance, in 
their pinkish-white tinge, somewhat nodulated or rounded outline, 
and their dense resisting feeling to the touch. 

The only question of diagnosis that occurs, then, is as between the 



550 DISEASES OF THE FAUCES. 

benign and malignant growths — a problem which should rarely pre- 
sent any difficulties. 

These growths should be removed by the scissors or the ecraseur, 
as they are pedunculated or sessile. I think, however, that cases 
which are not better treated with the cold-wire ecraseur are very 
rare. 

In Curling's case wider access to the tumor was obtained by en- 
larging the oral orifice by an incision through the cheek ; while Bot- 
tini made an incision through the soft palate, in order to more easily 
reach the tumor. The necessity for any such measures as these, I 
take it, will very rarely present, especially if we resort to the use of 
the snare ; the stiff wire loop of this instrument is easily manipulated, 
and can be carried with great facility over a tumor and adjusted 
about its attachments with sufficient accuracy to render the operation 
comparatively simple, even in cases in which the tumor has attained 
a large size. In Curling's case the tumor had formed adhesions to 
the palate. Of course in an event of this sort such attachments can 
easily be broken up by the finger or by any convenient blunt 
instrument. 

Tumors of the Oro-Pharynx. 

The oro-pharynx seems to afford an unfavorable site for the de- 
velopment of benign neoplasms ; medical literature furnishes us with 
but few examples of growths in this locality. Some cases have been 
reported of dermoid tumors. 



CHAPTER LXXL 

SARCOMA OF THE FAUCES. 

Our consideration of this affection will be based on an analysis of 
such cases as have been reported in medical literature, dividing the 
subject as before into : First, sarcoma of the soft palate and pillars 
of the fauces; second, sarcoma of the tonsils; and third, sarcoma of 
the pharynx. 

Sarcoma of the Soft Palate and Pillars of the Fauces. 

Etiology. — We find recorded in literature twenty cases of sarcoma 
originating in the structures of the soft palate. 

We should naturally suppose that sarcoma of the palate would be 
somewhat closely allied to that of the pharynx in its clinical history, 
and yet, curiously enough, we find that whereas in the latter the dis- 
ease belongs more particularly to the middle period of life, in the one 
under consideration it seems to skip this period and to occur either 
early or late in life. Thus, of the cases recorded, seven occurred 
beyond fifty, while nine were met with earlier than the forties. 
When compared, however, with the tonsil we find that sarcoma in 
this region seems to be common to every period of life, though with 
something of preponderance in the later years. 

Pathology. — Of the cases reported, four were round-celled, two 
spindle-celled, two myxo-sarcomas, one each of cylindroma, alveolar, 
and adeno-sarcoma, one case was mixed-cell, one was melanotic, and 
one was fibro-plastic in character. In six cases the character of the 
growth is not given. 

Sarcoma of this region seems to carry out, in a notable degree, 
the idea that this disease tends to localize itself, for we find that the 
lymphatics were involved in but six of the cases. That this was a 
serious complication is shown by the fact that there was recurrence 
in four cases, although one is reported as having been cured. 

The development of a sarcoma in the palate seems to be somewhat 
insidious, and its extension slow. In a majority of instances the 
neighboring tissues are not invaded. 



552 DISEASES OF THE FAUCES. 

When we consider the soft, fleshy character of the tumor and its 
location in a region so notably subjected to functional movements, 
we should naturally suppose that ulceration of the surface would be 
a frequent symptom. This has been observed in a number of the 
reported cases, although it is by no means a constant feature. 

Symptomatology. — The development of these tumors is somewhat 
insidious, and they give rise to notable symptoms only after they 
have attained such proportions as to interfere with the functions of 
the part. Where the growth is of such a character as to overhang 
the larynx, dyspnoea may be produced ; or if the tumor is movable it 
may lead to attacks of suffocation, especially when the patient is in 
a recumbent position. The secretion from the parts is naturally in- 
creased. In no case, so far as I know, has hemorrhage been a serious 
complication during the course of the disease, although slight hemor- 
rhage is reported in several cases. Ordinarily pain is not present, 
although in one case it seems to have been notably distressing. In 
no instance was the general health impaired ; in other words, sarcoma 
of the palate gives rise to no special cachexia. 

Diagnosis. — The characteristic reddish pink color and fleshy ap- 
pearance of the tumor in this region, together with its round contour, 
would naturally suggest either an adenoma, sarcoma, or fibroma. 
The microscope, however, should settle the diagnosis. 

Prognosis. — All the cases reported were operated upon, with the 
exception of two. In neither of these cases, however, does the report 
show the total duration of the disease ; hence it is difficult to form 
am r estimate as to how long a patient with sarcoma of the palate will 
live without operative interference. In general, however, it is quite 
clear that sarcoma in this region is not an especially malignant dis- 
ease, as is shown by the fact of successful operations, even after the 
disease has existed for a long time. 

We find that of the twenty cases there was death without opera- 
tion in three, death following operation in seven ; in eight cases the 
operation seems to have been successful, while in two the ultimate 
history is not given, although it is probable that both these cases 
succumbed later to the disease. This is a percentage which, con- 
sidering the ordinary malignancy of sarcoma, is to be considered as 
strikingly favorable, nearly one-half the cases being cured. It is in- 
teresting to note that of the four round-celled sarcomas, two were 
cured, while the other cases which were cured were respectively 
alveolar, spindle-celled, myxo-, and mixed-celled sarcomas. 

Treatment. — Foulis performed a lateral pharyngotomy, the object 
apparently being to overcome the serious complication of hemor- 
rhage in the fauces, inasmuch as the growth is reported to have been 



SARCOMA OF THE FAUCES. 553 

the size of an egg and probably could have been reached through the 
mouth. This danger of hemorrhage seems also to have been feared 
by Albert and Treves, the latter of whom ligated the carotid artery 
before operating, while the former placed a ligature in position for 
use in case of necessity. That this is a danger to be considered, how- 
ever, is hardly made evident by the report of cases. In all the other 
cases the operations were done through the mouth, the tumor either 
being enucleated, excised, or snared. No suggestion can be made as 
regards the special instrument to be used or special method to be 
pursued in these cases. The indications are to remove not only the 
whole of the neoplasm in the fauces, but any of the cervical glands 
which may have become invaded by the morbid process. 

Sarcoma of the Tonsil. 

If the number of cases reported in current literature is any indi- 
cation of the frequency of the disease, we find that carcinoma is by 
far the more common form, outnumbering the cases of sarcoma more 
than twofold. 

In most of the reported cases, the data are sufficiently full to 
warrant fairly definite conclusions being drawn. 

Etiology. — Sarcoma is usually regarded as a disease belonging to 
the earlier periods of life ; and yet, curiously enough, when invading 
the tonsil it seems to belong more particularly to adult life. 

We find but fourteen cases occurring before the age of forty, and 
twenty cases occurring later. Why this should be, it is at first sight 
not easy to explain. It certainly is a very striking fact, to one see- 
ing a large number of cases of disease of the upper air passages, that 
those lymphatics which go to make up the faucial and pharyngeal 
tonsils, especially the latter, play an exceedingly important part in 
morbid processes in the throat. It would seem that the lymphatic 
structures in this region in persons from five to fifteen years of age 
are exceedingly active, from fifteen to forty -five they are quiescent, 
and after forty-five they take on a renewed activity, of the nature of 
which we seem to be in entire ignorance except so far as we observe the 
outward manifestation in the symptoms referable to the air tract. 
This may suggest the cause of the development of a sarcoma in the 
tonsil in so large a proportion of cases during the earlier and later 
decades of life. 

As regards sex, twenty-eight cases occurred in males, nine in 
females, and in eight the sex is not reported. 

We usually expect to find a larger number of cases of malignant 
disease among males than among females, but the preponderance here 



554 DISEASES OF THE FAUCES. 

is perhaps unusual, and is only to be still further accounted for by 
the fact that the habits of life and the exposures to which men are 
subjected lead to the development of a diseased condition of the upper 
air passages, which may possibly exercise a certain predisposing 
influence in the development of malignant disease. 

Pathology. — A sarcomatous tumor when occurring in the tonsil 
presents the ordinary characteristics of this variety of neoplasm when 
met with in any other portion of the body. It belongs essentially to 
the connective-tissue series of neoplasms; hence, having its origin 
in this elemental tissue in some portion of the tonsil it develops ordi- 
narily somewhat rapidly, infiltrating and displacing the normal tis- 
sues and extending to the parts beyond. Its progress usually differs 
from that of carcinoma in that this form of malignant disease extends 
forward to the base of the tongue and palatine arches, whereas sar- 
coma shows a tendency either to remain stationary or to extend back- 
ward into the oro-pharynx. The only instance, so far as I know, in 
which it has been known to extend forward into the mouth was one 
in which the gums and palate were involved. In the majority of 
instances the disease diffuses itself into the surrounding parts, al- 
though occasionally we find it encapsulated. When the neoplasm is 
invested with a capsule, this does not necessarily define the limits of 
the tumor, for the reason that the sarcomatous tissue may in any 
given case be found beyond the capsular limit. 

The extension of the neoplasm is not only, as before stated, in- 
ward, encroaching upon the pharyngeal cavity, but it also penetrates 
the tissues of the neck, making its appearance externally, where it 
may assume considerable proportions and should not be confounded 
with the secondary enlargement of the lymphatic glands of the neck. 
When we consider the malignancy which the clinical history of these 
cases indicates, and which is manifested by the extension and dis- 
semination of the neoplasm, we should naturally expect this to be 
evidenced, in the very large proportion of cases, somewhat early in 
the history of the disease, by the involvement of the cervical glands. 
When there is dissemination of the sarcoma, there seems to be a 
greater probability of recurrence. 

Symptomatology.— The development of a sarcoma in the fauces is 
usually somewhat insidious, and it makes its presence known mainly 
by its mere mechanical interference with the function of the parts, 
rather than by any subjective symptoms. 

Hemorrhage was noted in seven cases, causing death in two in- 
stances, and was of such a serious nature in a third as to demand 
ligation of the common carotid artery. 

The further symptoms which develop as the growth increases in 



SARCOMA OF THE FAUCES. 555 

size are largely mechanical. Deglutition becomes interfered with, 
and dyspnoea is occasioned which may become distressing. The 
presence of the growth naturally excites an increased secretion, which 
adds much to the discomfort of the patient. In addition to this, the 
erosions or ulcers on the surface of the tumor naturally give rise to 
a discharge of somewhat ichorous and oftentimes ill-smelling pus. 

It would seem in some cases that a cancerous cachexia is almost 
as characteristic of sarcoma as of carcinoma, and yet this is not to be 
accepted implicitly, for it must be remembered that a sarcoma in the 
fauces assumes an exceedingly malignant form, more so perhaps than 
sarcoma of any other region. Moreover, it gives rise to symptoms 
which react in a very marked way on the general system. Add to 
this, the fetid discharges, repeated attacks of hemorrhage, and per- 
haps dyspnoea, and we have, I think, quite sufficient to account for the 
very marked cachexia which shows itself in these cases, without con- 
sidering it as due to a specific sarcomatous or carcinomatous dyscra- 
sia. Fixation of the jaw is a notable characteristic of carcinoma rather 
than of sarcoma. This symptom, however, was present in one case, 
and is probably to be accounted for by the fact that the neoplasm 
encroached upon the temporo-maxillary articulation in such a way 
as to give rise to a morbid deposit or an inflammatory process. In 
this same case suppuration occurred in the external tumor, in con- 
nection with a still further and rather curious complication, viz., a 
glossitis, affecting first one side of the tongue and then the other, 
which disappeared spontaneously, however, in a comparatively short 
time. 

Diagnosis. — While the commencement of the tumor is somewhat 
insidious, it is usually accompanied with a certain amount of injec- 
tion of the mucous membrane surrounding it, which, as before stated, 
may lead to the mistaken diagnosis of a quinsy. The absence of 
fever and of notable pain in deglutition, and other symptoms which 
accompany quinsy, ought soon to eliminate the question of a suppu- 
rative inflammatory process. The main interest in diagnosis is 
between carcinoma and sarcoma, and this can be positively settled by 
the microscope only. 

Prognosis. — As the result of its location, sarcoma in the tonsil is 
to be regarded as of nearly as great malignancy as carcinoma in this 
region. This view is not entirely sustained by an analysis of the 
cases reported, and yet such analysis goes very far toward establish- 
ing the truth of this assertion. In eleven of these cases no operation 
was done, and the patients succumbed at the end of periods varying 
from two and a half to fifteen months. Nine cases are reported as 
having been operated upon by lateral pharyngotomy, galvano-cautery, 



556 DISEASES OF THE FAUCES. 

ecraseur, and other methods, all of which resulted in death in periods 
varying from two to twelve months from the commencement of the 
disease. In six cases operations were done by which the disease is 
reported as having been successfully extirpated. In Hueter's case the 
operation seems to have been successful, but the patient died soon 
after of pneumonia. In Cozzolino's case death occurred seven 
months later from apoplexy, while Mickulicz's patient died three 
months after the operation, up to which time there apparently had 
been no recurrence. Zsigmondy's case was operated upon, and no 
recurrence is reported at the end of one month, while in White's, 
Pollard's, Jardon's, and Langenbeck's cases we have no record of the 
ultimate results of the operation. Of the remaining cases the reports 
are imperfect. 

The very great fatality of sarcoma in this region is undoubtedly 
largely dependent upon the fact that the lymphatic tissue of the 
tonsil is very intimately and closely connected with the lymphatics 
of the neck, as the result of which the cervical region becomes in- 
volved very early in the history of the disease, and in many cases, as 
we have seen, the tumor in this region assumes larger proportions 
than in the fauces. This not only complicates the operative pro- 
cedure which is resorted to for the extirpation of the growth, but, 
furthermore, adds greatly to the difficulties of completely removing 
every centre of sarcomatous development. In consequence of this 
latter, of course, recurrence ta"kes place in quite a large number of 
cases. 

Yet, while sarcoma of the tonsil must be regarded as an exceed- 
ingly fatal disease, we are certainly warranted in the assertion that 
in a small proportion of the cases the eradication of the neoplasm 
may be hoped for. 

Treatment. — The first and prominent indication seems to be the 
thorough extirpation of the growth by such means as will accomplish 
the end with the least degree of injury to surrounding parts ; while 
at the same time any danger of stimulating renewed activity of devel- 
opment in the sarcomatous process should be avoided. 

I have no personal experience with this form of neoplasm as 
affecting the tonsil, but I am disposed to be somewhat decided in my 
opinion that when available the cold- wire snare ecraseur should be 
resorted to. My preference for this is perhaps largely based on the 
successful issue in the case of sarcoma of the naso-pharynx, and the 
two cases of sarcoma of the nasal passages, referred to in other 
chapters, notably of the former, wherein the ill effect of the galvano- 
cautery seemed to be very strikingly illustrated, especially when it 
was used in the lower pharynx and in the region of the tonsil. It 



SARCOMA OF THE FAUCES. 557 

might be not improper to recall in this connection that in the case of 
sarcoma of the naso-pharynx referred to, the tonsil and lower pharynx 
were subsequently involved. 

In one case, success with ligation of the carotid and iodoform in- 
jections has been reported. I am disposed to think, however, in 
this case that the shutting off the blood supply had far more to do 
with the dissipation of the tumor than the injections. 

As regards those cases which involve the cervical tissues, of course 
the successful extirpation of the neoplasm can be accomplished only 
by lateral pharyngotomy. 

Sakcoma of the Pharynx. 

The tonsil, being the meeting-point of the hypoblast and the epi- 
blast in the development of foetal life, is a favorable site for the 
occurrence of neoplasms; and furthermore malignant disease in the 
tonsil takes the form of carcinoma rather than of sarcoma. Coming 
now to the pharynx, a region which belongs rather to the hypoblast 
alone, this tendency to neoplastic growth apparently disappears to 
a certain extent; and, furthermore, as regards malignant disease, there 
seems to be no very special preference as to the form which this 
takes ; for whereas, the pharynx being composed largely of connective 
tissue, we should naturally expect to find a notable preponderance of 
sarcomatous growths, as a matter of clinical observation carcinoma 
seems to be nearly as frequent and both forms much less frequent 
than in the lymphatic tissue of the tonsil. 

A striking difference is noted between sarcoma of the pharynx and 
sarcoma of the tonsil; while the latter is an exceedingly grave disease, 
with a fatal termination in the very large proportion of cases, the 
former is, as a rule, quite amenable to treatment. This can be 
explained only by the fact of the rich lymphatic distribution in the 
tonsil, and its close and intimate relation with the lymphatics of the 
neck. This results in a very early involvement of this latter region 
in the extension of the tumor. In the pharynx, on the other hand, the 
disease seems to be localized from the onset, owing to the lymphatic 
glands not becoming involved. 

Etiology. — We find that sarcoma in this region seems to be a. 
disease of middle age, in that most of the cases occur between thirty- 
five and fifty. As regards sex, the general rule of mabgnant disease 
obtains, that about two-thirds of these growths are met with in males, 
the proportion of males being not so great as we found to be the case 
in sarcoma of the tonsil. 

Pathology. — A sarcomatous neoplasm in this region presents no 



558 DISEASES OF THE FAUCES. 

features which differ in any essential degree from the same tumor as 
found in other portions of the air tract. As regards the variety of 
sarcoma, in many of the reported cases this is not specified, while in 
two it is reported as fibro-sarcoma, in two round-celled, in two 
spindle-celled, while there were one each of plexiform, giant-celled, 
albuminoid, fibro-myxo-sarcoma, and adeno-myxo-sarcoma. 

Clinical histories show that, while in a few of the cases reported 
the cervical glands were involved, in the majority of them this com- 
plication seems not to have been present. Of course, when this 
existed it must be accepted as a tendency to generalization. As 
regards any further tendency toward involvement of other organs of 
the body, I find no record of such, although, with reference to sar- 
coma of the tonsil, several instances are given in which some of the 
viscera were invaded. 

Symptomatology. — A sarcoma in the pharynx makes its presence 
felt, in the early history of the case, merely as a mechanical obstruc- 
tion to the ordinary functions of the parts, especially with reference 
to deglutition. In many cases this is the only symptom which pre- 
sents until the tumor has attained such size as to overhang the 
larynx and to interfere with the entrance of air. When this latter 
condition obtains, the dyspnoea is usually comparatively slight dur- 
ing waking hours, but is notably aggravated by the recumbent posi- 
tion. Secretion from the surface of the tumor itself is usually limited, 
although the accumulation of an excess of mucus, owing to the immo- 
bility of the parts, may become a notable symptom. The secretion 
is also liable to be stimulated to an extent by the presence of the 
growth. 

Pain is never in any way a prominent symptom; in fact, these 
growths develop in an insidious and painless manner, and their whole 
clinical history is marked merely by mechanical interference with the 
function of the fauces. Hemorrhage, so frequently met with in sar- 
coma of the tonsil, is not usually present. If the growth extends 
upward into the upper pharynx, or presses upon the soft palate, nasal 
respiration is interfered with and phonation is notably impaired. 

In no instance, so far as I know, was cachexia present. The gen- 
eral health usually becomes impaired, however, when the tumor has 
attained such size as almost to completely fill the pharyngeal cavity, 
rendering the swallowing of solids impossible. 

Diagnosis. — A definite diagnosis can usually be made only by 
microscopic examination of a portion of the growth. 

Pkognosis. — As before intimated, sarcoma of the pharynx is by no 
means the very grave disease which it is in the tonsil. If we examine 
the cases reported, we find that, in quite a large proportion of them, 



SARCOMA OF THE FAUCES. 559 

tlie disease seems to have been entirely eradicated. The course of 
the disease was unfavorable when the cervical glands were enlarged. 

When the sarcomas contained a large amount of fibrous tissue 
they got well, whereas among the fatal cases were round-celled and 
giant-celled sarcomas. 

Treatment. — These growths are easily accessible through the 
natural passages, and ordinarily require no incisions through healthy 
parts, although it may become necessary to make an incision through 
the soft palate. At the present day, with our improved methods of 
manipulation, it is doubtful if such a procedure would become neces- 
sary . In a number of instances in which the growth was encapsulated , 
and it seems to have been encapsulated in a large proportion of the 
cases reported, a linear or crossed incision was made through the in- 
vestment, and the growth simply enucleated by the index finger. 

When these tumors assume the pedunculated form, the most 
available method of operating would consist in placing the loop of 
the ecraseur around the pedicle and severing its connections. The 
question arises here, of course, as to the comparative advantages of 
the cold-wire loop or the galvano-cautery. The prominent justifica- 
tion for the use of the galvano-cautery ecraseur is in the avoidance of 
hemorrhage, though dangerous hemorrhage is not an accident to be 
anticipated. I am disposed to doubt whether this instrument should 
be given preference, especially when we consider the ease and sim- 
plicity of manipulation of the cold-wire snare. Moreover, by the 
slow manipulation of the steel wire, expending an hour or longer, if 
necessary, in slowly contracting the loop, the loss of blood can be 
very materially avoided. Moreover, we should always bear in mind 
the fact that the use of the galvano-cautery is capable not only of 
exciting inflammatory reaction but possibly of stimulating a re- 
currence of the growth. 

In many instances a preliminary tracheotomy was done before the 
removal of the neoplasm. The advisability of this course will be 
decided in each individual case by the symptoms present, and the 
character and the size of the tumor. In one case, before the opera- 
tion, the carotid artery was ligated, because the surgeon detected 
evidences of dilatation in this artery, and for this reason feared 
troublesome hemorrhage. 

If a case should present which from its special features should 
seem to demand the gaining access to the pharynx by external in- 
cision, the choice would lie between a lateral pharyngotomy and a 
subhyoidean pharyngotomy. 

If, after the primary operation for the removal of a tumor, frag- 
ments of sarcomatous tissue should be observed at the seat of the 



560 DISEASES OF THE FAUCES. 

wound, the question arises as to the destruction of this by the 
galvano-cautery or other measures, or its removal. I think there can 
be no question as to the advisability of removing it by means of 
the snare, or such other means as may be attended with the least 
danger of inflammatory reaction. Certainly the use of caustics 
should be resorted to with hesitation. 

It is scarcely necessary to add in conclusion that if any of the 
cervical glands are involved, it is the duty of the surgeon to remove 
them at the same time that the faucial tumor is extirpated. 



CHAPTER LXXII. 

CAKCINOMA OF THE FAUCES. 

This subject is subdivided, as in the previous chapter, into : First, 
carcinoma of the soft palate and faucial pillars ; second, carcinoma of 
the tonsil; and third, carcinoma of the oro-pharynx. 

Carcinoma of the Soft Palate. 

Etiology. — Perhaps the most striking fact elicited by a review of 
the literature of this subject is the remarkable predominance of male 
victims in carcinoma of the velum and pillars. Of course this can 
only be regarded as a coincidence, and, while somewhat remarkable, 
one possessing no clinical importance. 

As regards age, the majority of cases occur beyond middle life, 
thus obeying the ordinary rule in regard to malignant disease. 

The only other fact which is of interest in regard to etiology is 
the apparent development of malignant disease from non-malignant 
in some of the reported cases. 

Pathology. — It is a somewhat noticeable fact, in carcinoma of the 
soft palate, that it shows a tendency, at least, to confine itself to the 
tissues of the velum. Certainly a review of the cases would seem to 
establish this fact, or else they show that a cancer in this region runs 
such a rapid course that it produces death before neighboring regions 
have been invaded. Of course this is rather a tendency than an observ- 
able fact, since evidence of extension has been observed in all cases. 

An investigation of the primary origin of cancer in the soft palate 
would necessarily be somewhat speculative. Its probable source, 
however, is to be sought either in the muscular tissue or the mucipa- 
rous glands, presumably the latter, since cancer of muscular tissue 
is exceedingly rare. The glands penetrate the muscular tissues; 
hence these structures are involved secondarily. Its further exten- 
sion would seem to have some respect to the anatomical character of 
ihe surrounding structures. Thus, while in most cases the disease 
confines itself to the soft palate, its most frequent extension is 
through the pillars. 
36 



562 DISEASES OF THE FAUCES. 

There seems to be a very notable disposition of carcinoma of the 
fauces, when it commences in the glandular structures, to avoid the 
lymphatic tissues in its extension. In those cases, however, in which 
it commences in the lymphatic structure, as in the tonsil, it shows no 
hesitancy whatever in invading the other tissues, such as the glandu- 
lar or muscular structure of the soft palate and other surrounding 
parts. 

Most of the cases have been reported as simply carcinoma or can- 
cer, although the clinical histories would seem to indicate that the 
majority of instances were epithelial in character. In a case reported 
by Gross, an apparently benign warty growth of six months' stand- 
ing took on malignant action. This we regard usually as an exceed- 
ingly rare event, but, considering that it was reported by so careful 
an observer, must be accepted as an undoubted instance of this trans- 
formation. Similar cases have been reported by others. It is 
believed by a number of observers that a malignant transformation is 
by no means an uncommon result in leucoplakia. 

Symptomatology. — The early stages of the development of a can- 
cer in the palate give rise ordinarily to no symptoms other than a 
certain amount of mechanical interference with deglutition, while at 
the same time the voice assumes a muffled tone, its nasal resonance 
being absent according as the tumor obstructs the palato-pharyngeal 
opening. 

The mucous membrane covering the tumor is not usually inflamed, 
and there is no hypersecretion. 

As the tumor increases in size these symptoms become more 
marked, and in certain cases there is the additional symptom of 
dyspnoea when the growth projects over the orifice of the larynx. 

Pain, which is usually so characteristic of cancerous growth, does 
not seem to have been present in many of the cases reported. The 
absence of pain is probably to be explained by the fact that the 
growth develops in a soft and yielding tissue, and that the disease 
runs a somewhat rapid course. 

In a certain proportion of cases ulceration occurred comparatively 
early, and was attended of course with the ordinary discharge so 
characteristic of cancerous degeneration. 

I find no note made in any case either of mild or excessive hemor- 
rhage from the ulcerated surface during the progress of the disease, 
although it followed a recurrence of the disease after operation in one 
case. 

The dyspnoea may become so urgent in some cases as to demand 
tracheotomy. This symptom seems sometimes to be due to the in- 
terference with the passage of air into the larynx, and not to any 



CARCINOMA OF THE FAUCES. 563 

secondary affection of the air passages below; although excessive 
enlargement of the cervical glands may cause stenosis of the larynx 
by external pressure. 

The early development of the cancerous cachexia seems to have 
been a notable characteristic of the disease, in that in all cases in 
which this is specially noted it occurred within a few months after 
the commencement of the affection. 

Diagnosis. — The tumors which are found in this region are papil- 
loma, adenoma, fibroma, sarcoma, and carcinoma; the points in the 
differential diagnosis need not be referred to, for the microscopic 
examination will at once settle the real character of the growth. 

Prognosis. — It is scarcely necessary to state that the prognosis in 
these cases is exceedingly unfavorable. I find in the reported cases 
that in five instances death occurred without operative interference. 
The longest time which the patient survived the disease was nine 
months, while the shortest was seven. Five cases were subjected to 
operative interference, followed by death in from one to ten months. 
There was recurrence in each instance in from one to five and a half 
months, with the exception of Chassaignac's, whose patient died 
three weeks after the operation. In other cases reported the details 
are so imperfect as to render them of no prognostic value. 

Treatment. — In view of the excessive fatality which has attended 
the disease in the cases reported, and the almost entire failure of 
such operative measures as have been resorted to in arresting the 
progress of the disease, any suggestions as regards treatment would 
seem almost unnecessary ; and yet we are scarcely warranted in con- 
cluding that operative measures have not been of service; for, 
whereas we fail to determine that life has been notably prolonged, we 
certainly must recognize the fact that the comfort of the patient has 
been ministered to in no small measure, when we consider that after 
the removal of the tumor a recurrence may possibly be postponed as 
long as five and a half months. 

Carcinoma of the Tonsil. 

When we consider that carcinoma belongs essentially to the later 
years of life, and to a period when the peculiar structure of which the 
tonsil is composed is inert and practically in a state of atrophy, we 
should naturally suppose that this region would be comparatively 
free from the primary invasion of malignant disease. This is true 
when we compare the frequency of cancer in the tonsil with its fre- 
quency in other regions of the body ; but when we note the frequency 
with which the tonsil is invaded as compared with other regions of the 



564 DISEASES OF THE FAUCES. 

fauces, we find that in the very large majority of instances the disease 
apparently has its primary origin in this gland, although subse- 
quently it may invade the soft palate, pillars of the fauces, base of 
the tongue, and other regions. 

Etiology. — That the tonsil should present a more favorable site 
for the development of cancer than the fauces, is, perhaps, not diffi- 
cult to understand when we remember the character of the tissue 
found there, composed as it is almost entirely of epithelial structure. 

As regards the age at which it occurs, we find the same rule as 
governs the development of carcinoma generally. Malignant dis- 
ease, as a rule, is met with among females more frequently than 
among males ; yet, curiously enough, when it involves the tonsil the 
males outnumber the females more than two to one. 

The use of tobacco is said to have some influence on the develop- 
ment of buccal and faucial carcinoma. Statistics, however, do not 
seem to support this suggestion, certainly in reference to the develop - 
ment of the disease in the tonsil. The same probably can be said in 
regard to the use of alcohol. 

Pathology. — The assertion has been made that sarcoma is the 
most common form of malignant disease found in the tonsil, the 
statement being based on the fact that this organ is composed very 
largely of round-cell tissue, referring undoubtedly to the lymphatic 
structure of the tonsil. In the cases reported it is difficult to deter- 
mine, with any degree of accuracy, how many had their primary 
origin in the tonsil ; but we are bound to conclude, from the character 
of the reports, that a very large number of these instances were really 
cases of primary malignant disease of this structure. 

Statistics, I think, will show that carcinoma is much more fre- 
quent than sarcoma. But, in the large majority of instances, cancer 
of the tonsil manifests itself in the form of epithelioma. Why this 
should be true, we can easily understand from the minute anatomy 
and the development of the organ. 

As the result of the close and intimate connection between the 
lymphatics of the tonsil and the cervical region, secondary engorge- 
ment occurs very early in the history of the disease and becomes a 
prominent feature in its course. 

On account of the rich distribution of lymphatics in the neighbor- 
hood of the tonsil and its close connection with the cervical glands, 
we might infer that generalization of the disease might not be uncom- 
mon ; yet the clinical history of the cases observed would seem to 
indicate that this is not a result to be anticipated. 

Symptomatology. — The earliest symptom to which the disease 
usually gives rise is pain of a somewhat sharp and lancinating char- 



CARCINOMA OF THE FAUCES. 565 

acter on deglutition, which increases rapidly with the development of 
the tumor, until it finally becomes constant. This pain is usually re- 
ferred to the faucial region, but extends in the direction of the ear. 
In some cases the pain seems to locate itself in the ear entirely, giv- 
ing rise to no symptoms which direct attention to the throat. 

The increased flow of saliva is a somewhat prominent symptom, 
commencing quite early. 

The voice is affected according to the size of the growth. 

The secondary enlargement of the cervical lymphatics occurs very 
early in the history of the disease, and has been present in nearly 
every instance reported. This glandular enlargement may make its 
appearance and be very extensive even before the attention of the 
patient has been called to the existence of any faucial disorder. The 
cervical invasion comes on suddenly, and assumes large proportions 
from the outset, after which, as the disease in the fauces progresses, 
the cervical glands eularge somewhat slowly. When the disease has 
once fixed itself in the tonsil, it runs a rapid course, causing this 
infiltration of the cervical lymphatics very early in its history, after 
which this secondary enlargement remains practically quiescent. A 
suppuration of these tissues may occur, although this is compara- 
tively rare. 

Ulceration usually occurs during the second or third month of the 
disease, very rarely being delayed beyond the fourth month. When 
this symptom sets in, there is a noticeable increase of the secretions, 
which are of a whitish-gray color and of a somewhat tenacious con- 
sistency. The discharge from the ulcerated surface is not infrequently 
tinged with blood from the rupture of minute blood-vessels invaded 
by the disease. Of course no blood-vessel is safe from erosion which 
lies in the track of the ulcerative process ; hence an excessive hemor- 
rhage ma}- occur if the tonsillar or ascending pharyngeal arteries are 
involved, and this, though fortunately rare, is a complication that is 
liable to occur. 

Cough is not infrequently present, as the result either of the 
secretions in the fauces or of some slight secondary laryngitis or 
bronchitis. 

Coincident with the development of the ulcerative process the 
breath becomes fetid. The further development of local symptoms 
is dependent mainly on the proportions which the growth attains 
and the direction in which it extends. As a rule, this latter is into 
the soft palate and base of the tongue and forward into the cheeks, 
thus giving rise to more marked difficulty in deglutition. If it 
extends backward toward the larynx and encroaches upon its lumen, 
dyspnoea may occur merely as the result of mechanical interference 



566 DISEASES OF THE FAUCES. 

with the entrance of air to the lungs, or ceclema of the larynx may 
set in. If the tumor presses upon or in any way includes the 
Eustachian tube, the hearing may become notably impaired. We 
should naturally suppose that this would be a very frequent compli- 
cation, yet it is somewhat rare, owing to the fact that the disease 
does not readily pass over the posterior pillar of the fauces into the 
tissues beyond. 

Comparatively early in the history of the disease the patient 
commences to feel somewhat the effect of impaired nutrition, as shown 
by the loss of weight and slow emaciation. This is early followed by 
that peculiar condition which we recognize as constituting the cancer- 
ous cachexia, which is probably to be considered as a form of blood 
poisoning. 

Diagnosis. — The mere fact of a tonsil becoming enlarged in size, 
or the seat of any neoplasm in adult life, carries with it the suspicion 
that this augmentation is due to malignant disease, especially if the 
enlargement is unilateral. Of course mere hypertrophy of a single 
tonsil in adult life is not an unusual thing to meet with ; but if we 
meet with a case in which the clinical history shows clearly that a 
unilateral increase of size in the tonsil has been the result of recent 
development, in a patient between the ages of forty-five and sixty, the 
probabilities very largely point toward its being a malignant process. 

Any tumor which, developing near the tonsil, presses it out of its 
bed and causes it to protrude into the fauces, might possibly lead to 
an error in diagnosis, and yet it must be remembered that, when this 
occurs, the tonsil preserves its characteristic appearance of a soft 
whitish-gray mammillated surface, marked by the numerous orifices 
of the normal crypts ; while malignant disease, fixing itself on this 
organ, changes the whole gross aspect of the tissue, and shows itself 
by notable appearances to be a true neoplasm. 

There is something in the appearance of cancerous disease which 
is characteristic and almost unmistakable when it presents itself in 
superficial structures. The onset of the disease is marked by a cellu- 
lar infiltration of the tissues immediately beneath the mucous mem- 
brane covering the surface of the tonsil. As the result of this, the 
blood-vessels are displaced, the surface of the tonsil becomes bleached 
as it were, and presents a peculiar white aspect covered by shining 
mucous membrane, which, still maintaining its normal state, is 
stretched to an unusual degree. It presents, therefore, a dry, glazed 
aspect with a suggestion of thinness and transparency, through which 
we see a mass of what appears to be morbid tissue beneath. The 
normal mammillated surface of the tonsil is thus converted into a 
number of somewhat large rounded lobules. Here and there are seen 



CARCINOMA OF THE FAUCES. 567 

minute blood-vessels traversing the tissues immediately beneath the 
mucous membrane, and standing out prominent and well defined over 
the white background. This definition, as we may call it, of these 
minute blood-vessels is especially marked round the edges of the ton- 
sil, and constitutes a feature of the early development of malignant 
disease which possesses a certain amount of diagnostic value. The 
further changes consist in a more or less rapid increase in size of the 
organ, until, as the result of crowding of the tissues by the new de- 
posit, the superficial layer breaks down and an ulcerated process is 
the result. The ulcerated process presents appearances which also 
are quite characteristic. The surface presents a fine, almost granular 
appearance, is of a whitish color, with a slightly bluish or pinkish 
tinge, is usually traversed by minute fissures, and is coated with 
a scanty whitish-graj secretion. As the ulceration extends and its 
surface increases, these fissures also increase in extent and depth. 
The edges of the ulceration are usually raised somewhat above the 
ordinary surface, to meet a raising up, as it were, of the mucous 
membrane which overlaps it, the two surfaces meeting apparently at 
the apex of a circumvallate ridge, while the whole is surrounded by 
a well-marked areola of redness. This areola, moreover, is notably 
of a bright red, somewhat scarlet color, in contradistinction to the 
redness of the venous plethora. As the disease progresses and extends 
beyond the tonsil into the tissues of the surrounding parts, we have 
developed a new condition, which we may describe as a cauliflower- 
like appearance of the growth. In this we find the edges of the ulcer 
completely everted and lying over upon the mucous membrane be- 
yond, in such a way that somewhat extensive flaps here and there 
can be raised up by means of a probe and turned back again upon 
the ulcerated part. On palpation with the finger, both before ulcera- 
tion and later, the diseased surface gives the sensation of density and 
resistance which is almost unmistakable. This is particularly notice- 
able after the ulceration has occurred, when, on passing the finger 
over it, the different lobules which make up the growth easily differ- 
entiate themselves under the touch, and give forth a sensation of 
hardness which is simulated by no other diseased condition. 

The diagnosis, then, should not present many points of great 
difficulty ; nevertheless, the tumor should at once be submitted to 
microscopical examination. 

Prognosis. — As has been already suggested, malignant disease in 
this region runs a somewhat rapid course, owing to the constant 
motion and attrition to which the parts are subjected, and is an ex- 
ceedingly grave affection. 

In a number of the reported cases, no operation was attempted, 



568 DISEASES OF THE FAUCES. 

and the disease was allowed to run its course, except so far as local 
and palliative measures may have influenced its progress. 

In seven of these cases, six males and one female, with ages vary- 
ing from thirty-two to eighty -two, the disease ran its course in from 
two to sixteen months. 

It would seem, then, that we should regard carcinoma of the tonsil 
as a disease which, if allowed to run its course without interference, 
will certainly result in a fatal termination in from twelve to eighteen 
months. 

When, however, we come to investigate those cases which were 
operated upon, we find that there is little question that such meas- 
ures as snaring, curetting, and cauterization serve to postpone the 
fatal termination, and also add somewhat to the comfort of the patient: 

We find in glancing over the histories of these patients, that some 
of them died as the result of the operation, while the remainder suc- 
cumbed to recurrence of the disease. If we compare the average 
duration of life of those in the group of cases operated upon, with that 
in the group of cases in which no operation was done, the percentage 
in favor of the operation does not seem to be very great; and yet it 
must be borne in mind that in many cases the patients survived the 
operation and were free from the disease for periods varying from 
three to five months before recurrence set in. Furthermore, a num* 
ber of instances have been reported in which the operation was suc- 
cessful and the disease apparently completely eradicated. 

Treatment. — The indications for treatment are thoroughly covered 
in the brief allusions to the histories of the cases above given. They 
consist, of course, simply in the complete extirpation of the tumor at 
the earliest possible period. The important question to be decided 
upon in this connection is not so much what operation shall be re- 
sorted to as whether any operation is justifiable. This will depend 
entirely on the general condition of the patient, the extent of the 
tumor, and the probability of its successful removal. Of course if 
the cancerous cachexia has already manifested itself in a notable 
manner, and the tumor has already so extended itself to neighboring 
parts as to render its complete extirpation impossible, no operation 
will be attempted. When, however, the general condition of the 
patient warrants it and the tumor is accessible, there can be no 
question as to the advisability of removing it. 

The choice of the operation, whether by means of the wire-snare 
ecraseur, the galvano-cautery, the ligature, or lateral pharyngotomy, 
must be decided by the rules of general surgical procedure and the 
special indications in each individual case. There can be no question 
as to the preference which should be given to the use of the wire- 



CARCINOMA OF THE FAUCES. 569 

snare ecraseur, provided the character and contour of the faucial 
tumor will admit of its use. By this instrument either the wholo 
mass can be extirpated, or it can be removed piecemeal, much assist- 
ance being obtained by the local anaesthetic properties of cocaine. 
The objections to the galvano-cautery mentioned in the preceding 
chapter obtain equally in the discussion of the surgical treatment of 
carcinomas. 

Various operations have been resorted to for gaining access to the 
tumor by means of external incisions, most of which constitute really 
capital operations. 

They will be more fully described in the chapter devoted to the 
external surgery of the pharynx. The question of preliminary trache- 
otomy, which in many of the procedures was considered necessary, 
is one to be determined by the symptoms and conditions which pre- 
sent in each individual case. 

Cakcinoma of the Pharynx. 

It would seem that few regions of the body are more exempt from 
the invasion of carcinoma than the lower pharynx. 

An investigation of the current literature o± later years, however, 
would seem to suggest that perhaps this form of malignant disease 
is more frequent than was formerly supposed. 

Etiology. — In some of the cases recorded there seems to have 
been a history of local inflammatory disorders in the pharynx, exist- 
ing some time before the development of the malignant disease. That 
this had any influence in the subsequent changes can scarcely be 
supposed. 

Curiously enough, we find that the large majority of cases occur 
in females. Of those cases in which the sex is reported, seventeen 
were females, while but seven were males. 

It is somewhat interesting to note the early period of life in which 
malignant disease of the pharynx develops. In the fourth decade 
of life, between thirty and forty -three cases were reported; in the 
fifth decade, ten cases ; in the sixth and seventh decade, three cases 
in each ; while in the eighth decade but one is reported. 

In some of the cases there was the usual history of heredity, 
which, however, adds nothing new to our knowledge of the disease. 

Pathology. — The prevailing type of carcinoma which is observed 
in the pharynx is epithelioma. In none of the cases reported has 
any other form of disease been specified, although in some instances 
the neoplasm was reported simply as cancer. 

Its development would seem to follow the ordinary course of this 



570 DISEASES OF THE FAUCES. 

form of malignant disease when met with in the fauces, viz. , to de- 
velop somewhat rapidly into ulceration, with the usual concomitants 
of that complication, viz., mild hemorrhagic attacks or bloody dis- 
charges. 

As regards extension, in most instances this seems to have been 
downward, although in one case the reverse was true, the disease 
commencing in the upper portion of the lower pharynx and extending 
upward toward the pharyngeal vault. The pharynx belonging essen- 
tially, from an anatomical point of view, to the food tract, we should 
naturally expect any extension of malignant disease in this region to 
invade the oesophagus. This is reported to have occurred in ten of 
the cases given, while in six cases the larynx was invaded. In one 
instance both the larynx and oesophagus were invaded. 

With the excefjtion of a few of the cases reported, there seems to 
have been no tendency to generalization of the disease so far as an 
invasion of other organs is concerned, although the cervical glands 
in most instances seem to have been involved. 

While secondary enlargement of the cervical glands is an almost 
constant attendant of the disease, it does not seem in most of the 
cases to have played any very important part as complicating the 
primary neoplasm. 

Symptomatology. — As a rule, the earliest symptoms of the disease 
seem to have been insidious, the tumor commencing in one or the 
other lateral walls of the pharynx, and, growing by somewhat slow 
progress, gave rise to but slight interference with the functions of 
the parts, especially with reference to deglutition. In no case, so far 
as I know, was pain or hemorrhage a symptom of the earlier develop- 
ment of the disease. After the tumor has been present for some 
months, however, it seems to be the usual history, in many cases 
certainly, that it should take on a somewhat rapid growth, increasing 
in size, while at the same time new symptoms are developed with 
reference to mechanical interference with function, as well as pain 
and secretion. The tumor, developing in size, of course, more mark- 
edly hampers the function of deglutition, this being rendered exceed- 
ingly difficult or impossible for solids. The neoplasm extends now 
not only by projecting forward, but laterally, in such a way that the 
flexibility of the pharyngeal walls is destroyed ; hence the impairment 
of deglutition is not purely due to the mechanical obstruction of the 
tumor, but to the fact that the muscular tissues of the pharynx are 
practically destroyed. 

If the tumor extend upward, as occurred in a few instances, the 
symptoms are mainly confined to those with reference to deglutition 
and impairment of voice, while in the later stages ulceration takes 



CARCINOMA OF THE FAUCES. 571 

place, with its attendant secretion and attacks of hemorrhage. In no 
case reported has serious hemorrhage taken place from ulceration 
and destruction of arterial coats, such as we have seen to be the case 
in cancer of the tonsil; but the hemorrhage consists simply in oozing 
apparently from the ulcerated surface. 

Y/hen the disease extends downward it seems to attack indiffer- 
ently the larynx, the oesophagus, or both. When the former occurs, 
the additional symptoms of dyspnoea, with impairment or loss of 
voice and cough, are added. 

From a practical point of view, so long as the malignant disease 
confines itself to the pharynx the symptoms are mainly interference 
with function, hypersecretion, and in the later stages pain with slight 
hemorrhages. Curiously enough, however, even in advanced cases, 
pain referable to the region does not seem to be a very constant 
symptom when the parts are at rest, although it is present to a 
more or less distressing extent in the attempt at deglutition, which, 
especially after ulceration has taken place, becomes quite painful. 

Diagnosis. — In the earlier stages of the disease, before the tumor 
has assumed decided proportions, it would seem that a diagnosis 
would be exceedingly difficult. A local inflammatory area, perhaps, 
may possess a diagnostic significance. 

As the neoplasm enlarges, it presents to ocular inspection the 
ordinary appearances of an epitheliomatous growth, namely, a broad, 
somewhat flattened, infiltrated plaque of mucous membrane, of a 
whitish-gray color, with perhaps a suggestion of pink, and a notable 
inflammatory area of redness around it — this latter appearance being 
one of no little diagnostic value. On palpation, the mass presents to 
the touch the peculiar and characteristic hardness of carcinomatous 
infiltration, with a smooth, unbroken surface. 

The next stage of the disease consists in the development of 
ulceration, which is liable to occur quite early in the history of the 
disease. An epitheliomatous ulcer presents appearances which are 
not easily mistaken. The whole mass projects above the surface of 
the mucous membrane, while its central portion is usually depressed. 
It is ragged, of a yellowish-gray dirty color, and covered with a 
somewhat scanty, slightly opaque serum ordinarily tinged with blood, 
whose source is in the eroded capillaries. 

The further diagnostic points are dependent upon the symptoms, 
the early development of glandular enlargement, and finally on the 
removal of a small portion for examination under the microscope. 

Prognosis. — The pharynx must be regarded as a region in which 
malignant disease shows exceedingly fatal tendencies. This can be 
explained, in part certainly, by the fact that a cancerous neoplasm 



572 DISEASES OF THE FAUCES. 

here encroaches very early upon the food tract, and in many cases 
upon the air tract. The result of this is that the general health 
becomes notably impaired somewhat early in the history of the dis- 
ease. The exceeding gravity and fatality of the disease, I think, are 
very clearly indicated by the cases reported. Thus, of fifteen in which 
the histories are sufficiently complete to afford definite data, the 
average duration of life from the commencement of the disease until 
death occurred was but nine and a half months. The longest time 
which any patient survived was about twenty months, while in the 
majority of instances the patients lived but from three to eight 
months after the disease had set in. Of these fifteen cases, however, 
seven were operated on, while eight were not. In the latter the aver- 
age duration of life was eight and a half months, while the average 
duration of life in the cases operated upon was ten and a quarter 
months. 

Treatment. — The indications for treatment have already been 
shown with sufficient clearness in the discussion of the other features 
of carcinoma of the pharynx ; hence no suggestions further need be 
made. 



SECTION V. 
DISEASES OF THE LARYNX 



DISEASES OF THE LARYNX. 



CHAPTER LXXIII. 

THE ANATOMY OF THE LARYNX. 

The cartilaginous framework which with its contents constitutes 
the larynx is superimposed upon the tracheal rings, and practically 
consists of such a modification of these rings as fits it for the per- 
formance of its special function, namely, that of phonation. At the 
same time, the phonatory apparatus is so arranged that the larynx 
shall constitute a free and unimpeded channel for the current of air 
in inspiration and expiration. 

Caktilages. — The frame of the larynx (see Fig. 113) is composed 
of five principal cartilages, namely, the thyroid, the cricoid, the epi- 
glottis, and the two arytenoids. In addition to these, we find two 
small supplementary cartilages on each side, those of Santorini and 
those of "Wrisberg. 

The Cricoid (see Figs. 114, 115). — The cricoid is the foundation 
cartilage of the larynx, in that all the other portions rest upon it. It 
is practically the upper ring of the trachea, but so modified, thick- 
ened, and enlarged as to afford a support to the other laryngeal car- 
tilages and attachment of muscles. In shape, it bears a close 
resemblance to a seal ring, from which it derives its name. Its an- 
terior half is small, rounded, and convex, and affords attachment to 
the crico-thyroid muscles. The posterior half is the broad, expanded 
portion, corresponding to the seal of the ring. The upper surface of 
this portion is marked by two facets, for articulation with the ary- 
tenoid cartilages, the long diameter of these facets lying transversely. 
On the outer portion of this half of the cartilage are found two small 
depressions, which mark the points of articulation with the inferior 
cornua of the thyroid cartilage. 

The under surface of the cricoid is attached to the upper ring of 
the trachea. Its upper surface in front affords attachment to the 



576 



DISEASES OF THE LARYNX. 



cricothyroid membrane, and at the sides to the lateral crico-arytenoid 
muscles or glottis closers. The posterior surface of the expanded 
portion of the cartilage presents a ridge in the median line, which 

affords attachment to the fibrous 
tissue of the oesophagus, while 
on either side of this ridge there 
are shallow depressions, into 
which are inserted the fibres of 
the posterior crico - arytenoid 
muscles or glottis openers. 

The Thyroid (see Fig. 116).— 
The thyroid cartilage consists of 
two broad, flat, quadrilateral 
plates, as it were, united anteri- 
orly at a somewhat sharp angle, 





Fig. 114. — The Cricoid, seen Anteriorly 
(Broca). 1, Anterior portion; 2, poste- 
rior portion; 3, internal surface; 4, su- 
perior circumference; 5, inferior border. 



Fig. 113.— The Cartilaginous Frame of the Larynx, 
with the Ilyoid Bone and Ligamentous Attach- 
ments (Broca). A, Hyoid bone; B, B, the greater 
cornua of the hyoid: C, C, the lesser cornua of 
the hyoid; D, epiglottis; E, thyroid cartilage; 
F, F, the superior cornua of the thyroid; G, the 
lesser cornu of the thyroid; H, cricoid cartilage; 
1, thyro-epiglottic ligament; 2, hyo-epiglotticliga- 
ment; 3, lateral thyro-hyoid ligament; 4, median 
cri co-thyroid ligament; 5, lateral crico-thyroid 
ligament. 




Fig. 115.— The Cricoid, Upper Surface. 1, 1, 
Articular facets for the arytenoid car- 
tilages. 



thus constituting a broad protruding shield, which forms a 
large portion of the anterior and lateral walls of the larynx, and 



THE ANATOMY OF THE LARYNX. 577 

thus affords ample protection from external violence. The 
junction of the two broad plates or wings which form this carti- 
lage is marked anteriorly and above by a deep sulcus or notch, the 
thyroid notch. The posterior border of each ala is marked by two 
prolongations above and below, the superior and inferior horns or 
cornua. The upper cornua afford attachment to the thyro-hyoid 
ligament, while the inferior cornua articulate with the cricoid carti- 
lage, thus forming the only articular junction between the two carti- 
lages, although the attachment is completed by means of the crico- 
thyroid ligament and the crico-thyroid muscles. 

At the receding angle of the thyroid cartilage internally we find 
attachments, in the median line above, to the ligament of the epi- 



Fig. 116.— The Thyroid, Anterior Aspect (Broca). 1, Pomum Adami; 2, 2, quadrilateral surface of 
each ala; 3, 3, superior border: 4, 4, superior cornua; 5. 5, inferior border; 6, 6, inferior cornua. 

glottis, while immediately below this, on either side of the median 
line, are the attachments of the ventricular bands, and below these 
that of the vocal cords. Immediately without the point of attach- 
ment of the vocal cords are the points of insertion of the thyro- 
arytenoid muscles. The posterior border of each ala affords attach- 
ment to the stylo-phaiyngeus muscle, while immediately in front of 
these, and on the outer surface, are found successively the attach- 
ments of the inferior constrictor, the sterno-thyroid, and thyro-hyoid 
muscles ; while on the lower portion of the outer face of each ring is 
found the attachment of the crico-thyroid muscle. 

The Arytenoids (see Figs. 117, 118). — The arytenoid cartilages are 
so named from their resemblance to the mouth of a pitcher. They 
are small, three-sided pyramids, resting by their bases upon the 
upper surface of the posterior portion of the cricoid ring. The car- 
tilages are so situated that the internal faces of each are nearly par- 
37 



578 DISEASES OF THE LARYNX. 

allel. The anterior angle of each is prolonged, and receives the 
attachment of the vocal cord, while into the external angle of the base 
of each are inserted both the posterior and lateral crico-arytenoid 
muscles. The base of each cartilage presents a broad, oval depres- 
sion, for articulation with the facet already described on the superior 
margin of the posterior portion of the cricoid cartilage. This de- 
pression is much larger than the facet with which it articulates, thus 
allowing great freedom of motion. 

The apex of each of these cartilages is pointed, and bent slightly 
inward and backward. 

The Cartilages of Santorini (see Figs. 117, 118). — In the mucous 
membrane immediately over the apex of each arytenoid cartilage are 

Fig. 117.— Anterior Face of the Arytenoid fig. 118.— Posterior Face of the Arytenoid 
(Broca). 1, 2, 3, Facets for the insertion of (Broca). 1,. Facet for the insertion of the 

the ventricular band; 4, antero-internal ventricular band; 2, an tero-internal angle of 

angle of base or of vocal process; 5, caput the base, the point of insertion of the vocal 

Santorini. cord; 3, point of insertion of the posterior 

and lateral crico-arytenoid muscles; 4, facet 
for articulation with the cricoid; 5, caput 
Santorini. 

found ordinarily two small fibro-cartilaginous nodules, called the cor- 
nicula laryngis or cartilages of Santorini, which are of interest 
mainly from an anatomical point of view. 

The Cartilages of Wrisberg. — In each fold of mucous membrane 
which stretches from the arytenoid cartilages to the sides of the epi- 
glottis, namely, the ary-epiglottic fold, at about one-third the dis- 
tance from the arytenoids, there is found a slender, staff-like fibro- 
cartilage, the staff of Wrisberg, which is recognizable by a slight 
projection in the fold, immediately in front of the caput Santorini. 
This cartilage also seems to possess no special function in the human 
economy. 

The Epiglottis. — This is a thin plate of fibro-cartilage, shaped 
somewhat like a leaf, rounded above, and terminating below in a 
somewhat elongated pedicle, called the petiolus, which is attached to 
the receding angle of the thyroid cartilage, immediately below the 
notch, by means of a ligamentous band, the thyro-epiglottic liga- 
ment, in such a way as to allow the largest freedom of antero-lateral 
movement. Its anterior surface is convex from side to side, and 



THE ANATOMY OF THE LARYNX. 579 

concave from above downward, its superior border, as a rule, being 
curved forward over the base of the tongue, to which it is attached at 
its lower part in the median line by a band of fibrous tissue, the 
glosso-epiglottic ligament, while laterally the mucous membrane is 
thrown into two smaller folds, usually called the lateral glosso- 
epiglottic ligaments, although, according to Collier, no ligamentous 
tissue is found in these folds. The lingual face of this cartilage is 
studded with a number of minute depressions, which mark the site 
of the muciparous glands. The ary -epiglottic folds are attached to 
the sides of the cartilage. 

During the act of deglutition, the larynx is drawn up beneath the 
base of the tongue in such a manner that the epiglottis is drawn over 
the opening of the larynx, something after the manner of a trap-door, 
thus preventing the entrance of food into the air passages. It was 
formerly supposed that this trap-door function of the epiglottis was 
indispensable. Clinical experience teaches us, however, that the 
constrictors of the larynx exclude food from the air passages, even 
when the epiglottis is entirely destroyed by disease. 

In addition to the above cartilages, Luschka has discovered in the 
larynx several small cartilaginous structures which, although not in- 
variably present, possess a certain amount of interest. These are the 
posterior sesamoid cartilages, small oblong masses between the ary- 
tenoids and the cartilages of Santorini, to which they are attached by 
delicate bands of ligamentary tissue ; and the anterior sesamoid car- 
tilages, located in the anterior portion of the vocal cords, where they 
are inserted into the receding angle of the thyroid. They are minute 
in size, and separated from the thyroid cartilage by a layer of dense 
fibrous tissue. The inter-arytenoid cartilage is a small cartilaginous 
mass found, very rarely, between the arytenoids. 

Ligaments (see Fig. 113). — Outside of the larynx we find the thy- 
roid cartilage connected with the hyoid bone by means of the thyro- 
hyoid membrane and the two lateral thyro-hyoid ligaments. 

The thyro-hyoid membrane is a broad layer of fibro-elastic tissue, 
which extends from the upper border of the thyroid cartilage to the 
upper border of the hyoid bone, being separated from the inner sur- 
face of the latter by a synovial bursa. It is pierced in the median 
line by the superior laryngeal vessels and nerve. 

The lateral thyro-hyoid ligaments are rounded, cord-like bundles of 
fibro-elastic tissue, which extend from the superior cornua of the thy- 
roid cartilage to the greater cornua of the hyoid bone. A still fur- 
ther ligamentous connection between the hyoid bone and the larynx 
is found in the hyo-epiglottic ligament, a band of fibro-elastic tissue, 
which arises from near the apex of the epiglottis, and is inserted into 



580 DISEASES OF THE LARYNX. 

the posterior surface of the body of the hyoid. The laryngeal carti- 
lages themselves are bound together by a series of ligaments, which 
are usually spoken of as internal or intrinsic ligaments. The thyroid 
cartilage is connected with the cricoid by means of three ligaments, 
the crico-thyroid membrane and the capsular ligaments. 

The crico-thyroid membrane is a thick, elastic membrane which fills 
in the gap left between the upper border of the cricoid and the lower 
border of the anterior portion of the thyroid cartilage. Laterally it 
becomes blended with the anterior insertion of the true vocal cords. 
In the median line it lies directly beneath the skin, while laterally it 
is covered by the crico-thyroid muscles. It is crossed horizontally 
by a small arterial branch, forming an anastomosis between the crico- 
thyroid arteries of either side. On its inner surface the central por- 
tion is simply covered by the mucous membrane, while laterally it is 
covered by the thyro-arytenoid and lateral crico-arytenoid muscles. 
The connection between the thyroid and cricoid cartilages is com- 
pleted by the articulation of the inferior cornua of the thyroid with 
the sides of the cricoid. This is enclosed by a capsular ligament, 
within which is found a synovial membrane. 

Each crico-arytenoid joint is reinforced by loose capsular liga- 
ments, within which are synovial membranes. Posteriorly, however, 
the capsule is strengthened by a posterior crico-arytenoid ligament. 

The epiglottis is connected with the receding angle of the thyroid 
cartilage by means of the thyro-epiglottic ligament, a long, rounded, 
flexible bundle of fibro-elastic tissue. The epiglottis is also attached 
to the base of the tongue by the median glosso-ejjiglottic ligament and 
by two lateral folds, which, as we have seen, contain no ligamentous 
tissue other than the continuation of the pharyngeal aponeurosis. 

The Cavity of the Larynx (see Fig. 119). — In examining the lar- 
yngeal cavity, commencing from above downward, we first come upon 
the crest of the epiglottis, lying in the median line at the base of the 
tongue. This presents a more or less crescentic shape, but varies 
within the limits of normality in a very marked degree. The crest 
may present as the arc of a comparatively large circle, or it may be 
bent on itself to such an extent as to present the outline almost of a 
shepherd's crook, this latter condition being more characteristic of 
early life. As a rule, of course, the centre of the epiglottis is in 
alignment with the median line of the body, although not infre- 
quently we meet with a considerable deviation to one side. This 
does not, however, constitute a morbid condition. Beyond the epi- 
glottis we come upon the cavity of the larynx. This is bounded 
above by a plane sloping downward and backward from the crest of 
the epiglottis to the apices of the arytenoid cartilages above, and 



THE ANATOMY OF THE LARYNX. 



581 



below by a plane passing through the lower border of the cricoid 
cartilage. The entrance to the larynx is somewhat triangular in 
shape, and is bounded in front by the epiglottis, laterally hj two folds 
of mucous membrane, which stretch from the sides of the epiglottis 




V 3 






Fig. 119.— Antero-Posterior Section of Larynx, showing the Cavity after the Removal of the 
Mucous Membrane from Left Lateral Half (Broca). A, A, Hyoid bone; B, B, greater cornua of 
thyroid; C, C, section of thyroid at commissure; D, D, cricoid cartilage divided posteriorly; 
-B, E, anterior section of cricoid; F, F, arytenoideus muscle divided; G, posterior surface of 
epiglottis; 1, ary-epiglottic fold; 2, muscular fibres in the fold; 3, ventricular band; 4, true 
cord; 5, ligamentous portion of same; 6, thyro-arytenoid muscle; 7, ventricle; 8, internal sur- 
face of the crico-thyroid muscle. 

to the arytenoid cartilages, viz., the aryteno-epiglottidean folds. The 
laryngeal cavity is divided into two portions by the vocal cords, the 
opening between which is called the rima glottidis. That portion 
above the vocal cords is called the supraglottic portion, while that 
below is called the subglottic portion. 



582 DISEASES OF THE LARYNX. 

Immediately below the crest of the epiglottis is found a rounded 
prominence, the cushion of the epiglottis. This is really due to the 
prominence of the petiolus, although there is a certain amount of 
adenoid tissue, together with fatty matter, found at this point. Pass- 
ing from the side of the epiglottis to the apex of each arytenoid car- 
tilage is a fold of mucous membrane, the ary '-epiglottic fold, which is 
supported by ligamentous and muscular fibres. At the edge of this 
fold, immediately over the arytenoid, may be seen the prominence 
formed by the cartilage of Santorini, and in front of this the projec- 
tion of the cartilage of Wrisberg. 

Passing farther down into the cavity of the larynx, we come upon 
two folds of mucous membrane, one on either side, the ventricular 
bands, which extend in a horizontal plane from the receding angle of 
the thyroid to the arytenoid cartilages. These bands or folds of mu- 
cous membrane are supported by the superior thyro-arytenoid liga- 
ments, bands of elastic tissue whose attachments in front are on 
either side of the receding angle of the thyroid immediately below the 
attachment of the epiglottis, while posteriorly they are attached to the 
interior surface of the arytenoid cartilages. Immediately below the 
ventricular bands, or false vocal cords as they are sometimes called, 
is found on either side an oblong or elliptical fissure which separates 
them from the true vocal cords. These fosssG extend nearly the whole 
length of the vocal cords and the ventricular bands, and are called the 
ventricles of the larynx. They are bounded externally by the thyro- 
arytenoid muscles. In the anterior part of each ventricle is found a 
narrow, pouch-like cavity, lined with mucous membrane, the sacculus 
laryngis. This is a membranous sac, which extends up between the 
ventricular band and the inner surface of the ala of the thyroid carti- 
lage. It curves upward and backward, and is said to resemble in 
form a Phrygian cap. It varies greatly in depth in different persons, 
and occasionally is found extending as far as the upper border of the 
thyroid, and in rare instances it has been traced beyond the epiglottis 
to the base of the tongue. A large number of muciparous glands are 
found in the sacculus, which has led to the theory that this cavity 
constitutes a lubricating reservoir for the vocal cords. It is more 
probable, however, that it is merely a rudimentary survival of organs 
which obtain an enormous development in the quadrumana, reaching 
even to the shoulders and axillge. 

Immediately below the ventricular bands and parallel with them 
are found the true vocal cords. These are two stout fibrous bands 
composed of yellow elastic tissue. Anteriorly they are inserted into 
the lower portion of the receding angle of the thyroid cartilage, im- 
mediately within the insertion of the thyro-arytenoid muscles. Pos- 



THE ANATOMY OF THE LARYNX. -583 

teriorly they are divided into three sets of fibres, one of which is in- 
serted into the anterior angle or vocal process of the arytenoid carti- 
lage ; a second portion is inserted into the anterior face of the same 
cartilage, as high up as the ventricular bands ; while a third is in- 
serted into the capsular ligament which invests the crico-arytenoid 
joint, and also into the anterior face of the expanded portion of the 
cricoid ring. A cross-section of the vocal cord shows it to be a tri- 
angular prism, the apex of which presents to its fellow, while the 
base presents outward, and affords attachment in its whole length to 
the fibres of the thyro-arytenoid muscle. We thus find the vocal cord 
to be practically a ligamentous border of this latter muscle. The 
glottis or rwia-glottidis is the name given to the opening between the 
true vocal cords. In the male its length varies somewhat, but the 
average, probably, in the adult male is about seven-eighths of an 
inch. Anteriorly, of course, the cords are in contact. Posteriorly, 
when dilated to its widest extent, the opening will measure about a 
half -inch. 

An anomalous condition of the vocal cords is occasionally met 
with, which consists in a union which, commencing at the anterior 
commissure, extends backward from a quarter to half the distance to 
the arytenoid. This is usually described as a web of the vocal cords. 
It is a congenital condition, and consists in a union of the mucous 
membrane probably, rather than of the fibro-elastic tissue. 

The Muscles. — Various classifications have been made of the 
muscles which preside over the movements of the larynx, based both 
on physiological and anatomical investigation. Any classification 
which restricts each individual muscle to a particular function is to an 
extent misleading. They are presented here, therefore, without 
grouping. 

The most important muscles of the larynx and those which act 
directly upon the vocal cords are: the crico-thyroid, the crico- 
arytenoideus posticus, the crico-arytenoideus lateralis, the thyro- 
arytenoideus, and the arytenoideus. 

The Crico- Thyroid (see Fig. 120). — The crico-thyroid is a triangu- 
lar-shaped muscle, which arises from the anterior portion and side of 
the cricoid ring and divides into two fasciculi, one of which passes 
almost directly upward, to be inserted into the inner portion of the 
lower border of the thyroid cartilage anteriorly, while the other fas- 
ciculus passes obliquely upward and backward and is inserted into 
the lower border of the thyroid cartilage, immediately behind the in- 
sertion of the first fasciculus. 

It was formerly supposed that this muscle, acting from the cri- 
coid as a fixed point, drew the thyroid down over it in such a way as 



584 



DISEASES OF THE LARYNX. 



to produce tension and elongation of the vocal cords. Elaborate se- 
ries of investigations have shown conclusively that the thyroid is the 
fixed point, being rendered so by the action of the thyro-hyoid, ster- 




Fig. 120.— The Crico-Thyroid Muscle,Viewed 
Anteriorly (Broca). A, Hyoid bone; B, 
thyroid cartilage; C, thyro-hyoid mem- 
brane; D, cricoid cartilage; E, crico- 
thyroid membrane; F, trachea; 1,1, 
crico-thyroid muscle; 2, 2, origin of 
the muscle from the anterior portion 
and side of the cricoid; 3, 3, insertion 
into the lower border of the thyroid. 



Fig. 121.— -The Arytenoid and Posterior Crico- 
Arytenoid Muscle (Broca). A, Hyoid bone; 
B, B, posterior border of the thyroid; C, 
posterior face of cricoid; D, D, posterior 
border of the arytenoid; E, epiglottis; F, F, 
ary-epiglottic folds; <?, trachea; 1, ary- 
tenoid muscle; 2,3, oblique fibres of same; 
4, 4, crico- arytenoid posterior muscles; 5,5, 
their insertion in the outer angle of the base 
of the arytenoid cartilage. 



no-thyroid, and laryngo-pharyngeal muscles, and the cord is elon- 
gated and rendered tense by the cricoid being drawn upward and 
backward. 



THE ANATOMY OF THE LARYNX. 



585 



The Posterior Crico-Arytenoid (see Fig. 121). — The posterior crico- 
arytenoid muscles are somewhat triangular in shape, and arise from 
the posterior surface of the expanded portion of the cricoid cartilage, 
and have their insertion in the outer angle or muscular process of the 
base of the arytenoid cartilage. The action of each muscle, having 
its fixed point on the cricoid cartilage, is to draw the outer angle of 
the arytenoid cartilage backward, thus throwing its anterior angle or 
vocal process, to which is attached the vocal cord, outward, in this 
way acting as a glottis-opener (see Fig. 122). According to Ruhl- 
mann, each of these muscles is composed of two fasculi, the outer- 
most or more horizontal fibres acting to draw the whole of the aryte- 





Fig. 122.— The Glottis-Opening Action of the 
Posterior Crico-Arytenoid Muscles, shown 
by Diagram. 



Fig. 123.— The Glottis-Closing Action of the 
Lateral Crico-Arytenoid Muscles, shown 
Diagramatically. 



noid cartilage directly outward, away from its fellow, while the inner 
and lower fibres rotate it on its base. 

The Kerato- Cricoid Muscle. — Merkel describes a bundle of muscu- 
lar fibres which arises at the side of the cricoid origin of the poste- 
rior crico-arytenoid muscle, and is inserted into the posterior portion 
of the lower horn of the thyroid. He gives it the name of the kerato- 
cricoid muscle. Merkel states that it is unilateral, although Turner 
says that it is occasionally bilateral, and is found in twenty-one and 
eight-tenths per cent of cases. 

The Lateral Crico- Arytenoid. — These muscles have their origin on 
the upper border of the side of the cricoid cartilage, and, passing up- 
ward and backward, are inserted into the outer angle or muscular 
process of the arytenoid cartilage, immediately in front of the inser- 
tion of the preceding muscle. Having their fixed point in the cricoid 
they draw the outer angle of the arytenoid cartilage forward, thus 
throwing its vocal process inward and closing the glottis (see Fig. 123). 



586 DISEASES OF THE LARYNX. 

The Thyro- Arytenoid. — These muscles have their origin in the 
lower portion of the receding angle of the thyroid cartilage and the 
crico-thyroid membrane, and, passing backward along the outer side 
of the vocal cords, are inserted into the base and anterior surface of 
the arytenoid cartilage. Each muscle is composed of two fasciculi, 
the inferior and superior, or, as they are ordinarily called, the inter- 
nal and external. Each fasciculus arises from the receding angle of 
the thyroid. The internal passes backward and is attached to the vo- 
cal cord in its whole length, while posteriorly it is inserted into the 
external surface of the vocal process ; the external fasciculus spreads 
out more widel3 r , and is inserted into the interior face of the aryte- 
noid cartilage, as far outward as the muscular process. The fibres of 
this fasciculus pass under the sacculus laryngis. The action of this 
muscle as a whole is to approximate the arytenoid cartilages to the 
thyroid, thus shortening and relaxing the vocal cords. The action of 
the internal fasciculi is to bring the edges of the cords together, and 
they thus have an important function in the production of the high 
notes in the singing voice, while the external fasciculi have mainly to 
do with relaxation of the cords, and are also supposed to have a func- 
tion in compressing the sacculus laryngis. 

The Superior Thyro- Arytenoid. — In addition to the above, Schrot- 
ter describes a bundle of muscular fibres which he designates as the 
superior or oblique thyro-arytenoid muscle, which, having its origin 
near the receding angle of the thyroid, just above the former muscle, 
passes backward, outward, and downward, and is inserted into the 
muscular process of the arytenoid cartilage. It serves to re-enforce 
the action of the former muscle, especially in the finer movements of 
the singing voice. 

The Arytenoid. — The arytenoid is a single muscle which passes 
from the posterior surface and outer border of one arytenoid cartilage 
to the corresponding part of the opposite cartilage. It is usually de- 
scribed as composed of three layers, two oblique and one transverse. 
The oblique fibres pas 3 from the apex of one cartilage to the base of 
the opposite, and conversely. The transverse fibres, which are the 
deepest, pass directly across in a horizontal direction from one carti- 
lage to the other. A better anatomical division would be to describe 
the transverse fibres alone as composing the arytenoid muscle, while 
the oblique fibres belong to the ary-epiglottic muscles. The action 
of the arytenoid muscle is to approximate the artyenoid cartilages, 
and to close that portion of the rima glottidis which is included be- 
tween the vocal processes. 

The Thyro-Epiglottic and Ary-Epiglottic Muscles.— The muscles 
above described have their principal action upon the vocal cords. In 



THE ANATOMY OF THE LARYNX. 587 

addition to this, we have two muscles which act upon the epiglottis 
and the opening of the larynx, viz. , the thyro-epiglottic and the ary- 
epiglottic muscles. 

The thyro-epiglottic ha» its origin at the side of the receding an- 
gle of the thyroid cartilage, immediately external to the thyro-aryte- 
noid muscle ; it passes outward around the sacculus laryngis, and is 
inserted into the sides of the epiglottis, some of its fibres being lost 
in the ary-epiglottic fold. This muscle is supposed to act as a de- 
pressor of the epiglottis. 

The ary-epiglottic muscle arises from the posterior surface 
of the base of the arytenoid cartilage, and passes up in an oblique 
direction to the apex of the opposite arytenoid, to which it is 
loosely attached, and then passes forward in the ary-epiglottic 
fold, in which some of the fibres are lost, while others pass for- 
ward and upward over the inner and upper portion of the sac- 
culus laryngis, and are inserted by a broad attachment into the 
margin of the epiglottis, some of its fibres spreading on to its 
anterior surface. 

This muscle, therefore, with its fellow, makes almost a complete 
girdle around the entrance of the larnygeal cavity. In contraction, 
its action is necessarily to constrict the aperture of the larnyx, while 
at the same time probably some of its fibres net to compress the sac- 
culus laryngis. 

The Sterno-Hyoid and Thyro-Hyoid Muscles. — In addition to the 
above there are certain muscles, usually described as belonging to 
the infrahyoid region, which should be described in this connection, 
in that they possesss a somewhat important function in fixing the 
larynx during phonation. These are the sterno-thyroid and thyro- 
hyoid. The sterno-thyroid arises from the posterior surface of the 
manubrium of the sternum, and occasionally from the cartilage of the 
first rib, and has its insertion in the side of the wing of the thyroid 
cartilage ; while the thyro-hyoid arises from the side of the wing of 
the thyroid cartilage, immediately above the insertion of the sterno- 
thyroid, and, passing upward, is inserted into the lower edge of the 
body and great wing of the hyoid bone. The action of the sterno- 
thyroid, therefore, would seem to be to depress the larynx, while the 
thyro-hyoid elevates it. The two muscles, however, acting in har- 
mony, subserve the purpose of steadying the larynx during phona- 
tion, and thus enable the intrinsic muscles of the larynx to perform 
their function in phonation with a greater degree of nicety. This 
function is also aided somewhat by certain small muscular fibres, to 
which the name of the laryngopharyngeal muscle is given, which have 
their origin from the posterior border of the cricoid cartilage, and, 



588 



DISEASES OF THE LARYNX. 



passing backward round the pharynx, are inserted into the body of 
the fourth or fifth cervical vertebra behind. 

The Mucous Membkane.— The mucous membrane which lines the 
larynx is continuous with that of the pharynx and oral cavity above 
and with that of the trachea below. It covers both the anterior and 
posterior surfaces of the epiglottis, to which it is closely adherent, 
and is then reflected over the ary-epiglottic muscle, forming the ary- 
epiglottic fold, and subsequently over the superior thyro-arytenoid 
ligament, from which it passes into and forms the lining of the saccu- 
lus laryngis, and thence passes over the true vocal cords, where it 




Fig. 124. 



-Arterial Supply of the Larynx, Posterior View, showing the Distribution of the Superior 
Laryngeal Artery. 



forms an exceedingly thin and closely adherent membrane. Passing 
below the rima, it becomes continuous with the lining membrane of 
the trachea. Below the ventricular bands it follows the rule which 
governs mucous membranes lining the air tract, and is covered with 
columnar ciliated epithelium, with the exception of the true vocal 
cords, which are covered with squamous epithelium. Above the ven- 
tricular bands the ciliated epithelium is found on the lower half of 
the posterior face of the epiglottis. In the remaining portion the 
epithelium is of the squamous variety. 

The Muciparous Glands. — The lining membrane of the larynx is 



THE ANATOMY OF THE LARYNX. 



589 



richly endowed with muciparous glands, which are especially numer- 
ous upon the posterior face of the epiglottis, along the posterior mar- 
gin of the ary-epiglottic folds, and in front of the arytenoid carti- 
lages, as well as in the sacculus laryngis. 

Arteries. — The arterial supply of the larynx is derived from 
branches of the superior and inferior thyroid arteries, the superior 
thyroid being a branch of the external carotid, while the inferior is a 
branch of the thyroid axis. These laryngeal branches are divided 
into two sets, anterior and posterior. The anterior set consists of 




Fig. 125.— Arterial Supply of the Larynx, Anterior View, showing the Distribution of the Inferior 
Laryngeal, with the Origin of the Superior Laryngeal Artery. 

two branches, the superior laryngeal and inferior laryngeal, both 
branches of the superior thyroid artery. 

The superior laryngeal (see Fig. 124) passes inward in connection 
with the superior laryngeal nerve, between the greater cornu of the 
hyoid bone and the upper border of the thyroid cartilage, and enters 
the larynx through the thyro-hyoid membrane, after passing beneath 
the thyro-hyoid muscle. It is distributed to the epiglottis and to the 
mucous membrane, muscles, and glands of the upper and anterior 
portion of the larynx. 

The inferior laryngeal artery (see Fig. 124), or the crico-thyroid as 
it is often called, arises from the superior thyroid artery, almost im- 
mediately opposite the lower border of the thyroid cartilage, and 



590 DISEASES OF THE LARYNX. 

passes directly inward until it impinges upon the cricothyroid mem- 
brane, where it divides into two branches, the lower of which anasto- 
moses with a branch from its fellow of the opposite side, and, perfo- 
rating the membrane, enters the larynx, and is distributed to the 
mucous membrane below the vocal cords. The upper branch, passing 
beneath the border of the thyroid cartilage, anastomoses with branches 
from the superior laryngeal artery. A small branch also passes up 
on the outer face of the thyroid cartilage, and anastomoses with twigs 
from the hyoid branch of the superior thyroid artery. 

A second group is made up of the posterior laryngeal artery, which 
is a branch of the inferior thyroid. It passes upward in connection 
with the recurrent laryngeal nerve, until it reaches the posterior wall 
of the larynx near the crico-arytenoid articulation, where it divides 
into two branches, one of which is distributed to the posterior crico- 
arytenoid muscle, while the other passes upward, to anastomose with 
branches of the superior laryngeal artery. The course of the larger 
branches, as a rule, is quite close to the cartilaginous framework, 
while the smaller branches approach more nearly to the surface, 
where they are broken into a fine network. 

Veins. — The veins of the larynx follow the general course of the 
arteries, and empty into the superior, middle, and inferior thyroid 
veins, which terminate in the internal jugular. 

The Lymphatics. — The lymphatics of the larynx form a close net- 
work throughout the whole of its mucous membrane. They eventu- 
ally unite to form two main trunks on either side, viz., one above 
each ventricle and one below the cricoid cartilage. The upper trunk 
is formed by a union of the lymphatic vessels which are distributed 
to the epiglottis, and that portion of the larynx which is above the 
vocal cords, and passes out from the cavity, above the superior bor- 
der of the thyroid cartilage, and empties into the lymphatic glands 
which lie on either side of the larynx, near the anterior border of the 
sterno-mastoid muscle. The lower trunk is formed by a union of the 
lymphatic vessels which are distributed to the mucous membrane be- 
low the glottis, and, emerging from the larynx below the border of 
the thyroid cartilage, empties into the lymphatics distributed on 
either side of the trachea. These lymphatic trunks, as we have de- 
signated them, are made up of a group of several distinct vessels. 
The lymphatic distribution in the supraglottic portion of the larynx 
is exceedingly rich, while in the mucous membrane covering the 
cords and in the subglottic portion of the larynx it is somewhat 
diminished. 

Lymphatic tissue, according to Luschka, is not found diffused be- 
yond the mucous membrane of the larynx, but only at the borders of 



THE ANATOMY OF THE LARYNX. 591 

the epiglottis and in the ary -epiglottic folds. Rheiner believed that 
the presence of this tissue was an evidence of a catarrhal condition; 
while Heitler has found it distributed not only to the ary -epiglottic 
folds, but also to the mucous membrane over the arytenoids, and es- 
pecially over the cartilages of Santorini, in the inter-arytenoid and 
thyroid commissures, and in the anterior part of the laryngeal ven- 
tricles. So extensive is this aggregation of tissue in this last situa- 
tion that Hill has given it the name of the laryngeal tonsil. 

Nerves. — The larynx receives its motor and sensory innervation 
from the superior and the inferior or recurrent laryngeal nerves. 

The superior laryngeal nerve is a branch of the pneumogastric, 
which, according to the accepted view, supplies general sensation to 
the mucous membrane, and motor innervation to the crico-thyroid 
muscle and possibly to the arytenoid muscle. It has its origin in the 
inferior ganglion of the pneumogastric, from whence it passes down 
by the side of the pharynx, and divides above the superior border of 
the thyroid cartilage into two branches, the external and internal la- 
ryngeal. The external branch passes down on the outer side of the 
larynx, and pierces the crico-thyroid muscle. The internal branch 
pierces the thyrohyoid membrane' in connection with the superior 
laryngeal artery, and is distributed over the whole of the mucous 
membrane lining the laryngeal cavity and also to the base of the 
tongue, supplying general sensation. A filament is also sent to the 
arytenoid muscle. It also joins the recurrent laryngeal nerve. The 
motor filaments which supply the crico-thyroid and arytenoid mus- 
cles probably have their origin in the spinal accessory nerves. 

The inferior or recurrent laryngeal nerve supplies the muscles of the 
larynx with motor innervation, and is a branch of the pneumogastric, 
which it leaves, however, somewhat differently on either side. On 
the right side it arises on a level with the right subclavian artery, 
round which it winds from .before backward, and then passes upward 
and inward, approaching the trachea. On the left side it rises on a 
level with the concavity of the arch of the aorta, and, passing around 
this vessel, from before backward, ascends until it approaches the 
trachea, when it passes upward in the sulcus between it and the 
oesophagus. The nerve on either side passes up immediately behind 
the point of articulation of the lesser horn of the thyroid cartilage 
with the cricoid, and enters the laryngeal cavity, giving off branches 
to the posterior crico-arytenoid muscle, and also, according to Yon 
Ziemssen, sending sensitive branches which penetrate the muscles and 
are distributed to the mucous membrane of the laryngeal cavity below 
the glottis. As the nerve passes upward in the laryngeal cavity it 
distributes branches to the remaining muscles of the larynx, viz., the 



592 DISEASES OF THE LARYNX. 

lateral cricoarytenoid, the arytenoideus, the thyroarytenoids, the 
thyro-epiglottic, and ary-epiglottic muscles. 

The right recurrent nerve, after passing round the subclavian ar- 
tery, is in close contact with the apex of the lung of that side, an 
anatomical fact which it is important to remember in the rare in- 
stances in which we meet with right recurrent paralysis. 

The median larijngeal nerve, springing from the pharyngeal branch 
of the pneumogastric, is known to exist in some of the lower animals, 
and, while it has never been isolated in the human subject, Exner 
takes the ground that it is present, but so intricately involved in the 
pharyngeal plexus as to preclude an anatomical demonstration. He 
bases this view purely on physiological experimentation. -According 
to this observer, all the muscles of the larynx, with the exception of 
the exterDal thyro-arytenoid, receive motor innervation from more 
than one nerve — a fact which has been esteblished by Mandelstamm, 
who has shown that all the muscles of one side of the larynx not only 
receive double innervation from the superior and inferior nerve, but 
also by a sort of cross-action from the nerves of the opposite side. 
Exner takes the ground that this double innervation of the muscles 
establishes a general law. The crico-thyroid muscle, however, can 
be shown to receive innervation only from the superior nerve. In 
order, therefore, to bring this muscle under the action of the general 
law of double innervation, he argues the existence of a median laryn- 
geal nerve, supplying this muscle in connection with the superior. 

We thus find the laryngeal muscles endowed with an unusually 
rich nerve supply. Exner goes still further, and states that there 
is a great variation in individuals as regards the distinct source of in- 
nervation in each special muscle ; in other words, that in no two indi- 
viduals, probably, is the distribution of the nerve fibres to the laryn- 
geal muscles exactly alike. This view will serve to explain many of 
the curious features which are occasionally met with in cases of pa- 
ralysis of the laryngeal muscles. Exner fails to bring the external 
thyro-arytenoid muscle under his general law of double innervation, 
although in many instances he demonstrates a cross-action here by 
which this muscle receives innervation from the recurrent nerves of 
both sides. 

We are usually taught that the recurrent laryngeal nerve derives 
its motor fibres from the spinal accessory, and, moreover, that the 
spinal accessory is the sole source of motor innervation in the larnyx. 
Onodi, however, takes the ground that the larynx receives motor 
fibres which have their source in the spinal cord as far down as the 
lower cervical and first dorsal spinal ganglia of the sympathetic sys- 
tem, the course of the fibres being directly from the spinal cord to the 



THE ANATOMY OF THE LARYNX. 593 

first thoracic ganglion, then through the communicating branch be- 
tween this and the last cervical ganglion, and from this directly to 
the recurrent nerve. This will demonstrate how a destructive morbid 
lesion of the ganglia of the spinal accessory nerve may occur without 
resulting in the complete paralysis of the larnygeal muscles, they 
still receiving a certain amount of motor innervation from the spinal 
cord in the manner shown by Onodi. In this connection it should 
be stated that the motor fibres which innervate the larynx, and which 
reach the recurrent nerve through the spinal accessory, have their 
origin in that root of the spinal accessory which rises in the medulla 
oblongata. 
38 



CHAPTER LXXIV. 

THE PHYSIOLOGY OF THE LAKYNX. 

The larynx possesses two functions in the economy : It is endowed 
with certain movements constituting its respiratory function, and it 
also contains the mechanism by which the current of expired air is 
thrown into sonorous vibrations, which are subsequently converted 
into articulate language by means of the tongue, lips, cheeks, etc., 
thus constituting its function in phonation. 

The Function of the Laeynx in Eespiration. 

The general contour of the larynx in health is such that, while it 
opposes no obstacle whatever to the outgoing current of air in expira- 
tion, the ingoing current of air would be so far obstructed as to lead 
to serious consequences did not nature provide for the glottis being 
widely opened during inspiration, by muscular action. In other 
words, the tendency of the outgoing current of air is to open the 
glottis with little effort; the tendency of the ingoing current of air 
is to close it, the two vocal cords forming a valve, as it were, 
whose action is not unlike that of the mitral valves of the heart. 
With every act of inspiration, therefore, the glottis is opened by the 
posterior crico-arytenoid muscles. These muscles, as we know, 
arising from the posterior surface of the expanded portion of the cri- 
coid ring, pass outward and upward for insertion into the outer angle 
or muscular process of the base of the arytenoid cartilage. By their 
contraction they turn the arytenoid on itself, drawing its outer angle 
backward, thus throwing its anterior angle outward and opening the 
glottis. The opening of the glottis is still further accomplished by 
the action of the outer fibres of this muscle, which act to draw the 
whole cartilage outward on the elliptical facet, which, as we know, 
runs transversely on the cricoid cartilage. 

The respiratory function of the larynx, therefore, consists in this 
glottis-opening action of the posterior crico-arytenoid muscles. Dur- 
ing the act of expiration muscular action is simply relaxed, and the 
expired current of air makes a passive exit from the lungs. This 



THE PHYSIOLOGY OF THE LARYNX. 595 

glottis-openmg movement is purely of a reflex character, and is pre- 
sided over by the respiratory centre in the floor of the fourth ventri- 
cle. The action of this muscle is coincident with and excited by the 
same impulses which excite the ordinary muscles of inspiration. 

The respiratory act is excited primarily by the influence of the 
current of deoxygenated blood passing through the respiratory cen- 
tres, experiments having shown that the presence of carbonic acid in 
the venous blood passing through the medulla excites the respiratory 
act; and, furthermore, that as the carbonic acid increases these acts 
become more rapid and more vigorous. 

The Function of the Laeynx in Phonation. 

The phonatory function of the larynx is exercised by an exceed- 
ingly simple mechanism, by means of which the respiratory current 
of air is partially arrested by the approximation of the vocal cords, 
and is then driven through the chink thus formed in such a way that 
the column of air is thrown into sonorous vibrations, which are sub- 
sequently converted into articulate language by the parts above. We 
thus find that, whereas the respiratory function of the larynx has to 
do with the current of air in inspiration, the phonatory function has 
to do with the current of air in expiration. The larynx is thus en- 
dowed with two functions, which, however, by an exceedingly simple 
and yet harmonious adjustment of mechanism, are performed without 
interference ; in fact, the two functions seem to be supplementary to 
one another, the involuntary function of respiration being carried on 
during the intervals of the voluntary function of phonation. 

The action of the larynx is really that of a reed instrument, and 
the column of expired air is thrown into sonorous vibrations by the 
vocal cords. For the accomplishment of this purpose the cords are 
brought into apposition in the median line, and held firmly in posi- 
tion and rendered tense by muscular action, when the air is forced 
through by the respiratory muscles of the chest in such a way as to 
throw the edges of the cords into vibration. In this manner the col- 
umn of air in the upper air tract is also thrown into vibration, and, 
as has been stated, converted into articulate language by the move- 
ments of the tongue, lips, palate, etc. The muscles concerned in the 
approximation of the cords are primarily the lateral crico-arytenoid 
and the inter-arytenoid muscles, the former pulling forward the outer 
angle of the base of the arytenoid cartilages, thus rotating inward its 
anterior angle or vocal process, to which is attached the vocal cord, 
while the latter muscle simply brings into apposition the two aryte- 
noid cartilages. The approximation of the cords is thus an exceed- 



596 DISEASES OF THE LARYNX. 

ingly simple matter and one clearly understood. The mechanism by 
which the cords are rendered tense, however, is somewhat compli- 
cated. The muscles which are concerned in this function are the 
crico-thyroid and the thyro-arytenoid muscles. The action of the 
crico-thyroid is quite evident ; in drawing the cricoid cartilage up- 
ward and at the same time displacing it backward, the vocal cords are 
lengthened and rendered more tense. All authorities unite, I think, 
in the statement that the nicer tension of the cords is regulated by the 
thyro-arytenoid muscle. The apparent action of this muscle, passing 
as it does from the anterior face of the arytenoid cartilage to the re- 
ceding angle of the thyroid, is by its contraction to approximate the 
two attachments of the vocal cord, and thus produce relaxation. We 
must remember, however, that this muscle is made up of a number of 
fasciculi which are attached to the vocal cord in its whole extent, the 
vocal cord really being an aponeurosis of the muscle, as it were. It 
is quite a mistake to think that high tension of the vocal cords in- 
volves the necessity of their being stretched to their utmost between 
the arytenoid cartilage and the receding angle of the thyroid, thus 
bringing their edges into absolute parallelism; more probably, the 
tension of the vocal cords involves their edges being held in a state of 
firmness and rigidity, whether the chink be a straight line or an oval 
opening. In this way, the greater the rigidity of the cord the higher 
the number of vibrations per second into which it is thrown by the 
action of a column of air forced through the opening, therefore the 
higher the pitch of the sound produced. The vocal cords being then 
stretched from before backward, and rendered tense in the median 
line by the action of the crico-thyroid muscles, the thyro-arytenoid, 
whose fibres are attached throughout their whole length to the outer 
border of the cord, acts not only to increase this tension, but to give 
it that fine adjustment which is especially necessary in the higher 
powers of phonation, viz., in the singing voice. 

A still further action of the thyro-arytenoid muscle is that by the 
agency of those fibres which are distributed on the anterior face of 
the arytenoid and out toward the muscular process, the lateral crico- 
arytenoid muscle is re-enforced and the vocal processes approximated. 

The tension of the cords is aided somewhat by the inter-arytenoid 
and lateral crico-arytenoid muscles, which act to steady and hold 
firmly the arytenoid cartilage on its base. 

The epiglottis has been supposed by many to possess a certain 
function in phonation ; but the true and main function of this carti- 
lage undoubtedly is in closing the entrance of the larynx during the 
act of deglutition. 

The voice is endowed with pitch, intensity, and quality. The 



THE PHYSIOLOGY OF THE LARYNX. 597 

pitch of a voice depends solely upon the number of vibrations of the 
vocal cords. The greater the number of vibrations, of course, the 
higher the pitch. This is regulated entirely by the action of the 
muscles heretofore described. By the intensity of the voice is meant 
merely its loudness, which, of course, is dependent entirely on the 
amount of expiratory effort expended in driving the air through the 
chink of the glottis. The quality or timbre of the voice is that which 
gives each voice its special and individual character. This is largely 
dependent upon the general anatomy of the vocal apparatus, includ- 
ing the larynx, pharynx, nasal and accessory cavities. 

Each one of these cavities possesses a fundamental note. This 
fundamental note is constant in all except the mouth, where, of course, 
it varies according to its form and the position of the soft parts with- 
in it. 

Articulate speech is made up by a combination and modification 
of the elementary sounds, whose origin is largely in the larynx, yet 
not altogether, for, when we come to analyze carefully articulate 
speech, we find that it is only the vowel sounds which have their di- 
rect origin in the vibrations of the vocal cords, and that the conso- 
nants are formed by a modification or interruption of the expiratory 
blast in the throat, mouth, and nasal cavity. While the only sounds 
which are produced by the vocal cords are the vowel sounds, the pe- 
culiar characteristic of each vowel sound is the result of the positions 
which the mouth, tongue, and lips assume, this being different for 
each vowel. Furthermore, Helmholtz teaches us that the fundamental 
note of each vowel is invariable. In other words, that in the enunci- 
ation of each vowel sound the pharynx and mouth are placed in such 
a position that they form a cavity whose fundamental note is exactly 
the same for that vowel in all races and in all individuals. 

Consonants are produced entirely in the oral cavity by interrup- 
tions or modifications of the expiratory blast. Consonants may be 
divided into labials, dentals, and gutturals, according to the point in 
the oral cavity at which the interruption or modification of the expi- 
ratory blast occurs ; and these may further be divided into explosives, 
aspirates, and resonants, according to the manner in which the expi- 
ratory blast is interrupted or modified. 

In the formation of the whispering voice the anterior portions of 
the vocal cords are in approximation, while posteriorly a triangular 
opening is left between the vocal processes, through which the outgo- 
ing current of air rushes with a slight sound, which is formed into 
articulate speech by the tongue, lips, etc. The pitch of the whisper 
is always the same for each vowel and cannot be changed, and there- 
fore represents the fundamental note of the oral cavity in each instance. 



598 DISEASES OF THE LARYNX. 

Articulate speech, therefore, so far as the upper air passages are 
concerned, simply requires the integrity of innervation, motility, and 
contour of the larynx, pharynx, nasal and oral cavities, and lips. 
The tongue plays an exceedingly important part in the enunciation of 
most of the consonant sounds, and yet many cases have been reported 
in which the power of articulation was not seriously impaired after 
extirpation of the tongue. 

In more or less complete destruction of the soft palate and uvula, 
or in obliteration of the palato-pharyngeal space, the tone of the 
voice is seriously modified, and yet articulation is not materially in- 
terfered with. In the loss of the palate or in cleft palate, the diffi- 
culty is not so much in the movements of articulation as in the fact 
that the air escapes through the nasal passages, the patient not being 
able to force sufficient between the lips for use in articulation. The 
lips, therefore, are the parts most markedly brought into use in the 
process of articulation, and hence anything which interferes with their 
motility more seriously hampers this faculty than a morbid condition 
of any of the other parts involved in the function. 

The Singing Voice. — The ordinary conversational voice does not 
demand that the larynx and upper air passages shall be in a perfectly 
normal state ; indeed, we find this organ not infrequently the seat of 
notable morbid lesion without impairment of the conversational voice. 

In the use of the singing voice, however, it is not only essential 
that the larynx shall be normal in contour, properly innervated, and 
free from any inflammatory process, but that the whole upper air 
tract also shall be in a state of health. 

Probably every healthy larynx possesses the capacity for singing ; 
from a conventional point of view, however, we say that an individual 
possesses a singing voice who possesses the capacity of producing, by 
means of the larynx, the successive tones of the musical scale in such 
a manner as to afford an agreeable and harmonious impression to the 
ear. This faculty is not the natural endowment of the larynx, but 
one which is acquired only by practice or exercise. The idea of the 
singing voice, furthermore, involves the necessity of its possessing a 
certain range, usually in the neighborhood of two octaves. 

The finer points with reference to the singing voice, such as the 
definite position of the lips, tongue, palate, etc., in the production of 
the different notes, together with the action of the expiratory muscles 
and the management of the breath, are not entered upon here, for the 
reason that they belong more particularly to the technical works on 
voice culture. 

Ganglionic Cells which Preside over the Motor Innervation of the 
Larynx. — The ganglia which preside over the motor innervation of 



THE PHYSIOLOGY OF THE LARYNX. 599 

the larynx are situated, as we know, in the floor of the fourth ventri- 
cle. These ganglia, moreover, preside over all the movements which 
take place in the larynx, both voluntary and involuntary. A number 
of investigators go further than this, and claim to have demonstrated 
by physiological experiment the existence of a centre of laryngeal in- 
nervation in the cortex of the hemispheres. These experiments can- 
not as yet be regarded as conclusive. I am disposed to think that an 
element of confusion may have entered into the consideration of this 
subject, in that, whereas the centre of speech has been definitely lo- 
cated in the cerebral cortex, it seemed plausible that a motor centre 
might also be traced to this region. 



CHAPTER LXXV. 

LABYNGOSCOPY. 

The optical principles involved in laryngoscopy and its various 
appliances have already been described in a previous chapter. 

In making an examination of the larynx, the same general princi- 
ples apply here as in rhinoscopy, both in the management of the 
light and the use of reflectors, as also in the position of the patient. 
The only difference between the laryngeal mirror and the rhinoscopic 
mirror is in its size and the angle at which the mirror is joined to the 
shaft. For laryngeal examination it is well to make use of the No. 
4 or No. 5 mirror, and one in which the shaft is fixed to the reflecting 
disc at an angle of from 120° to 125°. The mirror is first warmed 
over the light to prevent the breath from condensing upon it and ob- 
scuring the image. Before its introduction it should be touched to 
the cheek or the hand to see that it is not too hot. The tongue of the 
patient should be protruded and seized between the thumb and fore- 
finger of the left hand, a napkin being interposed, and drawn gently 
forward and down over the lower lip. If preferred, this may be done 
by the patient himself, who should make use of the right hand. The 
shaft of the mirror should be held easily and gently in the hand, as 
one holds a pen. With its reflecting surface downward and parallel 
with the dorsum of the tongue, and the shaft held away from the me- 
dian line in such a position that it will strike the angle of the mouth, 
the mirror is passed backward until its edge touches the soft palate. 
It is then slightly inclined and passed downward and backward, until 
the uvula rests on its posterior surface, when without changing its in- 
clination it is carried backward and upward by a quick movement, 
lifting the uvula and soft palate with it, until it rests firmly against 
the wall of the pharynx. When in position it should rest trans- 
versely in the fauces, and be inclined at an angle of 45°. The patient 
should now be directed to sound a high-pitched "A" or "ah," as by 
this note the base of the tongue is depressed, the epiglottis lifted, and 
the larnygeal cavity brought well into view. In pressing the mirror 
against the pharynx, it is well to press with a firm hand, as there is 
less danger of causing retching in this manner than if the mirror is 



LARYNGOSCOPY 



601 



held free from the pharyngeal wall and unsteadily. The lower edge 
of the mirror should rest on the wall of the pharynx at a point above 
the free edge of the palate ; in other words, in the lower portion of 
the naso-pharynx, as this part is less sensitive than the oro-pharynx, 
and therefore retching is less liable to occur. By reference to Fig. 
127, the relative position of the parts and the position in which the 




Fig. 126.— Method of Making a Laryngoscopy Examination. 

mirror should be held will be easily understood, as well as the course 
of the illuminating and visual rays. Commencing at the light, the 
rays fall successively upon the reflecting mirror of the laryngoscope, 
from whence they are converged on the laryngeal mirror in the fauces, 
from which they are reflected upon and illuminate the laryngeal cav- 
ity. Eeturning now as visual rays, they travel back from the lar- 
ynx to the laryngeal mirror, and are then deflected to the eye. This 
diagram also illustrates the importance of making use of the small 



602 



DISEASES OF THE LARYNX. 



central aperture in the reflecting mirror for making the examination, 
as in this manner the illuminating and visual rays fall in the same 
line ; for instance, while the illuminating rays pass through the dotted 
lines shown, and illuminate that portion of the laryngeal cavity upon 
which they directly impinge, were the eye placed beyond the edge of 
the reflecting mirror, the visual rays are liable to be reflected by the 
throat mirror on a portion of the larynx not fully illuminated. The 
habit so often practised, therefore, of placing the head mirror on the 
forehead and looking beneath it is one to be avoided. 

The epiglottis is occasionally found so far overhanging the laryn- 
geal cavity as to seriously interfere with the examination. To over- 




Fig. 127.— Diagram showing the Principle of Laryngoscopy. 

come this difficulty various forms of hooks and pincettes have been de- 
vised. I have rarely met with a case in which these instruments were 
tolerated ; on the other hand, I have rarely met with a case in which 
this difficulty was not overcome and a satisfactory view of the parts 
obtained by the exercise of a little patience. As a rule, an overhang- 
ing epiglottis is the result of muscular contraction, and disappears 
as the patient becomes accustomed to the manipulation. The enunci- 
ation of a high note aids somewhat in lifting the epiglottis and over- 
coming the difficulty. The throwing of the head of the patient well 
backward also tends to open the laryngeal cavity. Irritability of the 
throat is probably the most obstinate and trying of all the difficulties 
encountered in making a laryngoscopic examination. We occasion- 
ally meet with patients in whom the mere opening of the mouth 



LARYNGOSCOPY. 603 

causes retching. In these cases nothing, perhaps, avails better than 
the application to the pharynx of a ten or twenty per cent solution of 
cocaine, though this should not be resorted to unless necessary, for 
the reason that the application of cocaine always results in tempo- 
rary inconvenience and discomfort to the patient. Much aid is often 
gained by simply directing a patient with an irritable throat to take 
short, quick respirations, the cool air striking the fauces seeming to 
cause a certain amount of local anaesthesia. Occasionally in young 
children I Lave often persisted in the examination in spite of retch- 
ing, the momentary opening of the larynx which accompanies the act of 
retching giving a fairly satisfactory, although but brief, inspection of 
the cavity. The best success in the laryugoscopic examination of a 
patient with an irritable throat is obtained by the exercise of patience 
and by a certain deftness and delicacy of manipulation, which is ac- 
quired with practice. Retching is merely the involuntary effort at 
deglutition excited by the presence of a foreign body in the food tract, 
the laryngeal mirror in this case being the foreign body ; the rule, 
therefore, already suggested, should be kept in mind, viz., that of 
pressing the palate well up, in order that the mirror may rest upon 
the walls of the naso-pharynx rather than of the oro-pharynx, as in 
this position retching is less liable to occur. A thick or unruly 
tongue may at times interfere with the observation, by obtruding 
itself or arching itself up in the line of vision. In such cases re- 
course must necessarily be had to the use of the tongue depressor, 
the examination being made without protruding the tongue. This is 
an excellent method for examining the larynx and one which may well 
be resorted to much more frequently than it is. If the fauces are nar- 
rowed hy large tonsils, this simply requires the use of a smaller mir- 
ror. An elongated uvula need not interfere with an examination, 
other than in rendering the fauces irritable. In such a case this or- 
gan can be easily caught on the back of the mirror and lifted out of 
the way. 

It is well to say that in making an examination the mirror should 
not be held in place more than from five to ten seconds, especially 
with patients not trained to tolerance of it, as a much more satisfac- 
tory examination will be accomplished by avoiding the wearying of 
the patient and the danger of exciting retching by too long an exam- 
ination. After the mirror has been placed in position, it should be 
held firmly against the pharynx and not moved about in search of the 
proper position and inclination for a view of the larnygeal cavity, as 
in this manner retching will be immediately excited. If it is desired 
to change the angle of inclination in order to bring into view the an- 
terior or posterior portions of the larynx, this is easily accomplished 



604 



DISEASES OF THE LARYNX. 



by simply turning the handle of the mirror between the fingers, thus 
changing the inclination of the reflecting disc without moving its 
position. 

The Laryngeal Image (see Figs. 128 and 129). — The reversal of the 
image in the mirror is simply the same that takes place when one 
looks in an ordinary dressing-mirror, and in making a laryngoscopic 
examination it is no more necessary to bear in mind that the image is 
reversed than it is when making one's toilet before a dressing-glass. 
Anatomy teaches the general relation of the individual parts of the 
larynx to each other, and hence it is well for those commencing the 
practice of laryngoscopy to make themselves thoroughly familiar with 
the regional anatomy of the parts. 

Having placed the mirror in the proper position in the fauces for 




Fig. 128.— The Laryngoscopic Image during 
Respiration. 



Fig. 129. 



-The Laryngoscopic Image during 
Phonation. 



an examination of the living subject, the first object that will be no- 
ticed is the epiglottis, standing up prominently in the upper portion 
of the mirror. It is of a pinkish-yellow color, the cartilage showing 
through the mucous membrane at its crest and borders. The upper 
border is of a somewhat crescentic shape, more or less curved upon 
itself, and presenting great variations in contour in different individ- 
uals, as has already been noticed. It may be seen in different posi- 
tions, varying from a fully erect one, in which the laryngeal cavity is 
completely exposed to view, to one in which it overhangs and largely 
conceals the cavity. If the anterior or lingual surface of the epiglot- 
tis is brought into view, there will be noticed three folds of mucous 
membrane passing from the epiglottis to the base of the tongue, one 
in the median line, the glosso-epiglottic ligament, dividing the de- 
pression between the epiglottis and the base of the tongue into two 



LARYNGOSCOPY. 605 

fossae, the lingual or glosso-epiglottic fossae. On the outer side of 
these fossae are seen slight folds of mucous membrane, which are 
sometimes designated as the lateral glosso-epiglottic ligaments, al- 
though they contain no ligamentous tissue. These fossae occasion- 
ally afford lodgement for particles of food and other substances, and 
should always be inspected in searching for foreign bodies in the 
throat. The posterior or laryngeal face of the epiglottis, just below 
the cavity of the larynx, is marked at about its centre by a rounded, 
pad-like prominence, of a deep red color. This is formed by the pe- 
tiolus of the epiglottis, and is usually designated as the cushion of 
the epiglottis. 

There will next be noticed two folds of membrane, passing down- 
ward and backward, one from each side of the epiglottis to the ary- 
tenoid cartilages, two small, rounded, knob-like prominences in the 
lower part of the image, which in the living subject are seen moving 
from a state of close proximity to one of wide separation in the acts 
of respiration and phonation. These folds of membrane are the ary- 
teno-epiglottic folds, or, as they are usually termed, the ary-epiglottic 
folds. They form the lateral walls of the laryngeal cavity, separating 
it on either side from the pyriform sinuses. In the posterior portion 
of the middle third of each fold will be noticed a small, knob-like pro- 
jection, which is formed by the cartilage of Wrisberg, and farther down 
a second rounded projection formed by the cartilage of Santorini, 
which, however, surmounting the arytenoid cartilage, simply serves 
to render it slightly more prominent, but, as a rule, cannot be distin- 
guished from it. 

Passing from one arytenoid cartilage to the other, and showing a 
slight depression or notch between them, especially noticeable when 
the cartilages are in approximation, will be seen a fold of membrane, 
the arytenoid commissure, which completes the circuit of the lumen 
of the larynx as follows : The epiglottis in front, the ary-epiglottic 
folds showing the cartilages of Wrisberg and Santorini forming the 
lateral wall, and the arytenoid cartilages and commissure posteriorly. 
Immediately behind this commissure will be noticed a closed fissure, 
between it and the wall of the pharynx, which is the orifice of the 
oesophagus. 

Going back now to the ary-epiglottic folds, there will be noticed 
on the outer side of each a somewhat pyramidal-shaped cavity, the 
pyriform sinuses. These sinuses are bounded by the inner wall of 
the thyroid cartilages externally, the outer face of the ary-epiglottic 
folds internally, and the posterior wall of the pharynx posteriorly, 
where they approximate one to the other and pass down into the 
oesophagus behind the arytenoids. At the bottom of each sinus may 



606 DISEASES OF THE LARYNX. 

be seen or felt a projection formed by the superior cornu of the hyoicl 
bone. These cavities afford a favorite site for the lodgement of fish- 
bones, particles of food, or other substances, and should be carefully 
searched in looking for foreign bodies. 

Passing again to the interior of the larynx, the first object noticed 
below the ary-epiglottic folds are the two ventricular bands, or, as 
they are sometimes improperly called, the false cords. These are 
two folds of mucous membrane, one on either side, which pass from 
the receding angle of the thyroid cartilage anteriorly, where they are 
nearly in apposition, to the arytenoid cartilages posteriorly. They 
are somewhat rounded, prominent folds of mucous membrane, sup- 
ported by the thyro-arytenoid ligaments, and presenting a deeper red 
color than the other portions of the laryngeal cavity. They move 
with the arytenoids, and are parallel with the vocal cords. Imme- 
diately below the border of the ventricular bands is seen a dark line, 
which separates them from the true vocal cords below. This line or 
fissure marks the entrance of the ventricles of the larynx. Imme- 
diately below the ventricles we come upon the true vocal cords, two 
white, glistening bands, moving back and forth with the acts of pho- 
nation and respiration. Their color is due to the fibrous tissue of 
which they are composed showing through the mucous membrane 
which covers them, this latter being extremely thin and supplied very 
sparsely with blood-vessels. The space of opening between the vocal 
cords forms the rima glottidis. When in apposition the rima is 
merely a straight line extending from the receding angle of the thy- 
roid cartilages to the arytenoid commissure. When the cords recede 
from one another and are relaxed, a little, knob-like projection is 
seen immediately in front of the arytenoid cartilage, and about one- 
fifth to one-fourth of the distance between it and the receding angle of 
the thyroid. This is formed by the cartilaginous prolongation of the 
anterior angle of the base of the arytenoid, viz., the vocal process. 
During the act of phonation the cords are brought into close approxi- 
mation, and in this manner any inspection of the parts below is pre- 
vented. During the act of inspiration, however, the cords are widely 
separated, and, if the mirror is properly adjusted and the illumina- 
ting ray sufficiently powerful, the subglottic portion of the larynx and 
the rings of the trachea may be brought under inspection, and in fa- 
vorable cases the bifurcation of the trachea may be observed with the 
opening into the right bronchus. The position of the mirror in the 
fauces being, as a rule, posterior to the axis of the trachea, its ante- 
rior wall is brought into view, with its rings, surmounted by the cri- 
coid cartilage. If it is desired to inspect the posterior wall of the 
trachea, this is accomplished only by bringing the laryngeal mirror 



LARYNGOSCOPY. 607 

slightly forward in the fauces. Even a moderately overhanging epi- 
glottis will ordinarily interfere with the success of this manipulation. 
When such an inspection becomes important two mirrors may be 
used. 

In general, it may be said that the lining membrane of the larynx 
is of light rose-pink color, with a tendency to a yellowish tinge, espe- 
cially when the cartilages are seen through on the surface, as at 
the crest of the epiglottis, on its sides, at the prominences made by the 
cartilages of Wrisberg and Santorini, and on the anterior wall of the 
trachea where the rings are manifest. At all these points the mem- 
brane is of a light pinkish-yellow color. Again, where the membrane 
covers a mass of glands, lymphatics, or loose connective tissue, it is 
of a deeper red color. This is noticeable on the cushion of the epi- 
glottis, the epiglottic folds, the arytenoid commissure, and the ven- 
tricular bands. 

In making a laryngoscopic examination, the first thing to observe 
is the general appearance of the mucous membrane, to determine 
whether it is discolored in any way, or whether it shows evidences of 
any of the forms of inflammatory action. The general contour of the 
laryngeal cavity should then be inspected, to ascertain the existence 
of neoplasms, or whether there may be loss of tissue from ulceration 
or any destructive process; and,- finally, the movements of the cords, 
both in phonation and respiration, should be examined, to determine 
whether they are perfectly approximated in the median line, and the 
readiness with which they are abducted in inspiration, and, further- 
more, whether their movements on both sides are perfectly symmetri- 
cal. In determining this latter point, it should always be borne in 
mind that the epiglottis is not infrequently deflected to one side or 
the other. Ordinarily, in making a laryngoscopic examination we 
bring the centre of the epiglottis into alignment with the arytenoid 
commissure. If, however, the epiglottis is deflected to one side, an 
alignment of this kind will so far distort the image of the part below 
as to give, not infrequently, the impression of marked deficiency of 
movement, or even paralysis, of one side of the larynx. Hence one 
should acquire the habit of inspecting the lower portion of the laryn- 
geal cavity without reference to the epiglottis. 



CHAPTER LXXVI. 

ACUTE LABYNGITIS. 

In former times this term was used to designate an acute inflam- 
matory affection involving the mucous membrane of the larynx, 
marked by the occurrence of extensive swelling, usually of an cede- 
matous nature, with notable interference with respiration; while to 
the mild form of inflammation of the mucous membrane lining the 
larynx the term subacute laryngitis was given. The term subacute 
is objectionable; and I think it is better to designate as an acute lar- 
yngitis that variety of the disease which was formerly described as 
subacute ; that form which is accompanied by extensive swelling of 
the parts we will consider in the chapter on phlegmonous laryngitis. 

The affection is not a serious one, the inflammatory process con- 
fining itself mainly to the mucosa proper, without involving the 
deeper tissues. Its principal interest lies in the fact that the voice is 
notably impaired and perhaps lost. 

Etiology. — We are generally taught that a sore throat or an acute 
laryngitis is the result of an exposure to cold, and this undoubtedly 
is the immediate exciting cause of the attack in the large majority of 
instances ; but, underlying this, I think almost invariably we shall 
find that there exists a mild chronic inflammation of the mucous mem- 
brane of the larynx, which, under the influence of an exposure, takes 
on an acute exacerbation. Furthermore, I am disposed to think that 
an inflammatory process in the larynx is very rarely, if ever, a pri- 
mary affection, but is secondary to an inflammatory process involving 
some portion of the air tract above. This is either an obstructive le- 
sion of the nasal cavity proper, or some morbid process in the naso- 
pharynx. 

Eecurrent attacks of hoarseness, with loss of voice, should always 
call attention to the probable existence of some diseased condition 
above the vocal organs. 

It occurs at all ages. Before puberty, as a rule, we find it sec- 
ondary to hypertrophy of the pharyngeal tonsil. During the second 
and third decades of life it is more liable to occur in connection with 
some form of rhinitis, while in later years it is dependent upon, in 



ACUTE LARYNGITIS. 609 

inost instances, a chronic nasopharyngeal catarrh. Among the rarer 
causes of the disease are the inhalation of irritating vapors, such as 
chlorine, iodine, ammonia, sulphur, etc., or the breathing of a smoke- 
laden atmosphere, from tobacco, wood, or coal. Overtaxing the voice 
in public speaking, singing, or shouting may also bring on an 
attack. 

Men are more liable to attacks than women, simply because they 
are more exposed to colds and more frequently suffer from chronic 
catarrhal troubles. 

The occurrence of an acute laryngitis at the onset or during the 
course of an attack of measles, scarlet fever, diphtheria, typhus and 
typhoid fevers, is usually unimportant. The graver complications in 
the larynx which occur in connection with the exanthemata are due to 
a perichondritis or chondritis, and not to a catarrhal inflammation of 
the mucous lining. 

Mention should be made in this connection of the acute laryngitis 
which occasionally follows the administration of drugs, iodide of po- 
tassium being especially active in this direction. The laryngeal hy- 
peremia from such causes is almost invariably accompanied by a 
similar process in the nasal mucous membrane. 

Pathology. — The changes which occur in the membrane consist 
primarily in a dilatation of the blood-vessels, with an arrest of secre- 
tion in the muciparous glands. This is soon followed by the second 
stage, which consists in the pouring out of a moderate amount of se- 
rum from the blood-vessels, together with increased secretion of mu- 
cus from the glandular structures. The inflammatory process usually 
is most active in those parts of the larynx where the mucous mem- 
brane is loosely attached to the parts beneath, as in the ary-epiglottic 
folds, the arytenoid commissure, and the ventricular bands. The 
mucous membrane of the cords consists practically of epithelial cells 
and a minute network of blood-vessels. At this portion of the larynx 
we have, therefore, merely dilated blood-vessels, without increased 
secretion. The laryngeal mucous membrane below the glottis is 
rarely involved to any extent ; when this, however, occurs, it becomes 
the seat of considerable swelling and injection. The mucous mem- 
brane of the epiglottis rarely presents any marked evidence of inflam- 
matory action. 

Symptomatology. — The prominent and most notable symptom in 
connection with an attack of this affection lies in the impairment of 
the voice, which may be hoarse or completely lost. Complete loss of 
voice in an attack, however, is almost invariably the result of exten- 
sive swelling of the arytenoid commissure, or possibly of the sub- 
glottic membrane, therebv interfering with the approximation of the 
39 



610 DISEASES OF THE LARYNX. 

cords. It is exceedingly rare to meet with a case of acute laryngitis, 
even of an aggravated form, in which a vocal tone cannot be produced, 
provided sufficient effort be made. A patient is usually disposed to 
use the whispering voice, even when phonation is possible. This is 
undoubtedly due, in part, to the fact that phonation requires a labored 
effort. 

Cough is occasionally present but is rarely troublesome, and when 
present is due to a complicating tracheitis. If the subglottic portion 
of the larynx, however, is involved, the cough is liable to be trouble- 
some and persistent. It is, however, exceedingly rare to meet with 
an acute subglottic laryngitis in an adult. 

Pain is not ordinarily present, although there is usually a feeling 
of soreness about the region, with slight tenderness on external press- 
ure or digital manipulation. 

Painful or difficult deglutition is present only when the disease 
accompanies an acute pharyngitis or some acute affection of the parts 
above the vocal organs. 

The disease is purely a local one, and ordinarily is attended with 
no marked systemic disturbance, although, if it accompanies or com- 
plicates an acute affection of the naso-pharynx or nasal chambers, it 
may be attended with loss of appetite, headache, and other evidences 
of mild febrile disturbance. 

Diagnosis. — The recognition of the disease is easily made by the 
character of the voice, although the laryngoscope should always be 
made use of to determine the amount and extent of the inflammatory 
process. 

An examination of the parts simply reveals the whole mucous 
membrane lining the larynx of a bright red color, the tint of the mem- 
brane being deeper in those parts which are loosely attached, such as 
the ary-epiglottic folds, ventricular bands, and the arytenoid commis- 
sure. The appearance of the vocal cords in this affection is often in- 
dicative of the extent of the inflammatory action, and hence these 
should always be inspected with especial care, their appearance fre- 
quently indicating the severity of the attack. In a mild case we may 
see simply the enlarged blood-vessels in the membrane thrown into 
strong relief by the white tissue of the cord beneath. If the attack is 
more severe the whole cord presents a pale pinkish tinge, while in 
still more aggravated cases we observe a deep red, beefy appearance 
in the membrane, not only of the cords but of other portions of the 
larynx. 

If the subglottic portion of the larynx is involved, which, as be- 
fore stated, is a rare event, this is recognized only when the cords are 
in a state of abduction, when the membrane below will be seen bulg- 



ACUTE LARYNGITIS. 611 

ing out in a rounded mass, symmetrical on either side, of a deep 
red color, and notably encroaching on the lumen of the subglottic 
region. 

The movements of the cords, as seen by examination, are normal 
in character, although their excursion is somewhat hampered by the 
swelling of the membrane, and while abduction is normal and com- 
plete, adduction is imperfectly accomplished, not so much as the re- 
sult of impaired muscular action, as from the fact that the movements 
of the arytenoids are interfered with by the swelling of the mucous 
membrane of the commissure. The chink of the glottis, moreover, in 
phonation, assumes a somewhat wider elliptical shape, on account 
of the impairment of tension, as exerted by the thyro-arytenoid 
muscles. 

The diagnosis need not necessarily depend entirely upon laryngo- 
scopy examination, in that a careful analysis of the symptoms will 
usually clearly indicate the seat and extent of the inflammatory pro- 
cess. The loss or impairment of voice sufficiently points to the 
larynx as the seat of the disease, while the absence of cough, with 
expectoration, eliminates the question of a bronchitis. This, taken in 
connection with the absence of febrile disturbance, is usually suffi- 
cient to render the diagnosis clear. 

Course and Prognosis. — The disease runs its course in from five to 
ten days, and usually undergoes spontaneous resolution. It involves 
no dangers to life. Its main importance is in the impairment of func- 
tion which it entails. 

Treatment. — If the attack comes on in connection with an acute 
inflammatory process involving some portion of the passages above, 
the primar}' indications for treatment consist in measures directed to 
these parts, sufficiently described in the earlier chapters, and fre- 
quently it will be found that the laryngeal disease disappears without 
further interference. While these measures in all cases have a 
marked effect on the morbid process in the larynx, and in many are 
sufficient without further treatment, the local applications to the lar- 
yngeal membrane itself undoubtedly aid very much in hastening a 
cure. I can understand objection to local measures only on the 
ground that the applications are made by means of the brush, sponge, 
or probang, and therefore the injurious effect is the result of the in- 
struments used rather than of the local astringent. The larynx is 
easily reached by means of the ordinary atomizers, such as those 
shown in a preceding chapter ; and in applying topical remedies to 
this organ, therefore, an atomizer should always be used. In this 
way we not only fail to irritate the parts, but it has been my unvary- 
ing experience that the use of astringents is attended with the best of 



612 DISEASES OF THE LARYNX. 

effects in this disease. The agents to be used are, in the order of 
preference, as follows : 

Liquor ferri persulphas, . . . . gtt. 5 to 10 to § i. 

Argenti nitras, gr. 2 to 5 to § i. 

Zinci chloridum, gr. 5 to 10 to § i. 

A better local effect, perhaps, is obtained by first spraying out the 
larynx with a mild solution of borax, soda, or any mild unirritating 
cleansing lotion. These applications may be repeated daily until en- 
tire relief is given. I question if steam inhalations are of very much 
value in acute laryngeal inflammations, in shortening the duration of 
the disease, although when compound tincture of benzoin, camphor, 
oil of tar, oil of eucalyptus, oil of turpentine, or the oleoresin of cu- 
bebs is added to the boiling water they undoubtedly give notable re- 
lief to subjective symptoms, especially at the onset of tlje attack, 
when the membrane is dry and the parts are stiff and painful. 

I have never been convinced that counter-irritants, in the form of 
blisters, poultices, or hot fomentations, produce any notable effect in 
an acute laryngitis. Cold applications to the neck by means of an 
ordinary ice bag or cold wet cloths frequently changed will often serve 
to cut short an attack of acute laryngitis, if undertaken early enough 
and persisted in for a sufficient time to test their efficacy. 

The value of throat lozenges in an acute affection of the larynx is 
very questionable and need not be further discussed. 

General medication is not specially indicated in acute laryngitis, 
although early in the disease it is always well to administer a saline 
laxative, and put the patient on small doses of quinine for a few days, 
or, better still, to administer five or ten grains of salicin three times 
daily until the attack passes away. If there is much irritation of the 
larynx, and the cough becomes a symptom of any prominence, we are 
often compelled to administer seme anodyne. Lactucarium often an- 
swers a good purpose in these cases; it is a harmless drug, and may 
be given quite freely. An excellent form for its administration is in 
the lozenges sold in the drug-stores under the name of Pate Auber- 
gier. Failing this, we may administer codeine in doses of from one- 
eighth to one-sixth of a grain, repeated every four hours. 

We are often, called upon by public singers or speakers, seeking 
relief from a hoarseness or a complete loss of voice, when it becomes 
a matter of some importance that the disability should be relieved at 
the shortest possible notice. I know of no definite method by which 
such a result can be unfailingly secured in any given time. The fol- 
lowing measures, stated in the order of their importance, seem to 
give the best results : First, absolute and total rest of the voice, the 



ACUTE LARYNGITIS. 613 

patient being directed to utter no tone above a whisper, and even the 
whispering voice to be avoided as much as possible. Second, con- 
finement to the poom, which should be kept at a fixed temperature of 
from 68 3 to 70° F., not above; while, at the same time, ample venti- 
lation is secured without involving a draught of air. Third, charg- 
ing the atmosphere with an abundance of moisture by means of 
steam generated from a spirit lamp, or some other equally unobjec- 
tionable method. Fourth, the application of cold to the surface by 
means of the ice bag. Fifth, the application to the larynx of a solu- 
tion of nitrate of silver, five grains to the ounce, by means of an 
atomizer, to be repeated a second or third time during the day ; the 
interval of the application and the strength of the solution being gov- 
erned somewhat by the subjective symptoms resulting, and by the 
laryngoscopic appearances. Sixth, if the turbinated bodies are 
swollen, they should be reduced by an application of chromic acid. 
Seventh, if there is an acute inflammation of the membrane lining the 
vault of the pharynx, this should be thoroughly douched by the post- 
nasal syringe, and an application made of a solution of nitrate of sil- 
ver, thirty grains to the ounce, while at the same time the patient 
should be placed under the influence of aconitine, one five-hundredth 
of a grain being given every hour until three doses have been given, 
and afterward every two hours until the constitutional effects are ex- 
perienced, as evidenced by the prickling of the fauces, tingling of the 
lips, or reduction of the pulse. Eighth, the bowels should be kept 
open by a saline laxative; this is especially indicated if the naso- 
pharynx is involved. 



CHAPTER LXXVIL 

ACUTE LARYNGITIS IN CHILDREN. 

In young children the glottis is not only much narrower than in 
adults, but the mucous membrane is more highly vascular and more 
loosely attached to the parts beneath. An acute laryngitis, therefore, 
at this period of life pursues a somewhat different course, and hence 
it seems wise to consider it under a separate heading. Moreover, 
there are two varieties, dependent on the portion of the larynx which 
is involved. In certain cases that portion only of the mucous mem- 
brane which is above the vocal cords is affected, and the attack runs a 
somewhat mild course ; while in those in which the mucous membrane 
below the vocal cords is involved the symptoms are of a much more 
alarming character; the breathing space is much encroached upon, 
and certain systemic symptoms are manifested which add markedly 
to the gravity of the affection. 

The majority of cases, probably, occur between the first and fourth 
years. 

Acute Supraglottic Laryngitis. 

This is a mild form of inflammation of the mucous membrane lin- 
ing the larynx, which is practically identical with that which occurs 
in adults, so far as the etiology and symptoms are concerned. Its 
predisposing causes are mainly mild catarrhal conditions of the up- 
per air tract, while the exciting cause is usually exposure to cold. In 
many instances it occurs in connection with an attack of acute rhini- 
tis, although it may develop without any apparent complicating dis- 
turbance of the parts above. The onset of the attack may be marked 
by a slight febrile movement and loss of appetite, or it may come on 
without any apparent constitutional disturbance. The voice becomes 
hoarse, and in rare instances is completely lost. Well-developed 
cough is not usually present, although there is a sense of irritation 
in the larynx which gives rise to a slight hacking attempt at clearing 
the throat. Tenderness of the parts is a constant feature of the 
disease. 

The inflammation here confines itself mainly to the mucous mem- 



ACUTE LARYNGITIS IN CHILDREN. 615 

brane covering the ventricular bands, the posterior commissure, and 
the vocal cords. The swelling of the mucous membrane is but slight, 
and dyspnoea is rarely if ever present. Spasm of the glottis seldom 
occurs in this form of laryngeal inflammation. 

Supraglottic laryngitis, therefore, is really of a rather trivial 
character. The diagnosis is based mainly on the absence of febrile 
disturbance, the coincident attack of acute rhinitis, and the character 
of the voice, which is hoarse rather than aphonic. The tenderness 
over the larynx is a symptom of diagnostic value. 

If it is possible to secure a laryngoscopic examination, this, of 
course, will add much to the certainty of the diagnosis. This exam- 
ination is much more easily made in young children than is generally 
supposed, and I think in all cases it should be attempted. 

The disease runs its course in from one to two weeks, and involves 
no dangerous tendencies other than the possible supervention of the 
subglottic form of the disease, although it must be borne in mind al- 
ways that a catarrhal laryngitis may occur in connection with measles 
and other of the exanthems. The primary stage of a croupous in- 
flammation of the larynx is an acute catarrhal inflammation. The 
exudation, however, makes its appearance so rapidly and occurs in 
connection with such high febrile disturbance that any doubt in diag- 
nosis is cleared up in a comparatively few hours, the croupous disease 
being rapidly progressive, while the simple catarrhal inflammation 
under consideration develops its most serious symptoms at the onset 
of the attack. 

Although this form of acute laryngitis in children involves no 
grave tendencies, yet we must all recognize the fact that a mucous 
membrane in a state of acute inflammation affords a favorable nidus 
for the lodgement and absorption of the disease germ of diphtheria. 

If the disease occurs in connection with an acute rhinitis, the 
measures directed to the nasal cavity become of the first importance. 
For this purpose the following may be used : 

]$ Cocainse muriat., gr. ij. to iv. 

-Aquae, v\, xv. 

M. fiat solutio et adde 

Glyceriti acidi tamrici, 3 i. 

01. petrolati, ad 1 i. 

This should be applied by means of the nasal atomizer every two 
or three hours. The cocaine is used to diminish vascularity, while 
the tannin has the effect of checking secretion. The above may be 
used in watery solution, although I think a certain permanency of 
action is secured bv the fluid vaselin. For the tannin in the above 



616 DISEASES OF THE LARYNX. 

prescription, any of the simple astringents may be used, probably 
with equally good effect. 

The bowels should be kept mildly open by some preparation of 
rhubarb, or, better still, possibly, castor oil. External applications 
to the neck and chest of camphorated oil or amber oil will be found 
to be particularly efficacious. I doubt if inhalations of steam for 
this form of disease are of any permanent service, although it is 
wise to confine the child for a few days in the nursery kept at an 
equable temperature, while at the same time the atmosphere is well 
surcharged with moisture. 

Acute Subglottic Lakyngitis. 

In this form of the affection, while the mucous membrane through- 
out the whole of the larynx is in a state of mild inflammation, that 
portion below the glottis is swollen and infiltrated to such an ex- 
tent as to give rise to dyspnceic symptoms, often of an alarming 
character. 

This is an affection which is oftentimes described in medical 
literature as false croup, spasmodic laryngitis, and laryngismus 
stridulus. 

Etiology. — The exciting causes of this form of disease differ in no 
essential degree from those which give rise to an attack of the supra- 
glottic form. Beyond this, however, there are certain predisposing 
causes which seem to be particularly active in the developing of an 
inflammatory process in the subglottic tissues of the larynx ; for while 
to the milder or supraglottic form the term " croup" does not espe- 
cially apply, in that there are no prominently croupy symptoms, to 
this form of the disease the term " croup" seems to be particularly 
appropriate, in that the hoarse, barking, stridulous cough, with dys- 
pnoea, etc., which are so characteristic of an attack, are admirably 
described by this term ; and when we use " croup" here, it is to be 
understood that we refer to the term as it is conventionally used, 
rather than as defining a morbid process which is attended by the 
development of a false membrane. 

We are usually told that it occurs with equal frequency in strong, 
healthy children and in weakly children. This is only partially true, 
for, whereas its victims usually show no marked evidences of malnu- 
trition, yet probably in a large proportion of instances we shall find 
that they are suffering from a tendency toward the involvement of 
lymphatic tissues, under the influence of which children develop en- 
larged tonsils, hypertrophy of the lymphatic tissue in the pharyn- 
geal vault, etc. ; and, while not constituting fully developed struma, it 



ACUTE LARYNGITIS IX CHILDREN. 617 

is a condition which, if carried a step farther, would result in a stru- 
mous habit. The important influence of this lymphatic habit in the 
development of catarrhal affections of the upper air passages is a 
matter of frequent clinical observation. 

While the lynrphatic habit is the most frequent predisposing 
cause of subglottic laryngitis, it is altogether probable that it arises 
in conditions where this habit does not exist. Bad hygienic sur- 
roundings, insufficient nourishment, improper clothing, and general 
causes of this kind undoubtedly predispose to it. Prolonged crying 
may give rise to sufficient laryngeal irritation to induce the disease. 

How frequently a simple catarrhal rhinitis or other affection of 
the upper air tract, aside from lymphatic enlargement, may act in 
producing a subglottic laryngitis it is not easy to say. Undoubtedly 
such may occur. On the other hand, we may have cases of the mild 
or supraglottic form of laryngitis occurring with lymphatic enlarge- 
ments, in connection with marked evidences of the lymphatic habit, 
as shown by the enlarged faucial and pharyngeal tonsils. I am dis- 
posed to think, however, that in a large majority of cases a laryngitis 
which arises in connection with engorged lymphatics in the passages 
above will take on the subglottic form ; while a laryngitis which arises 
in a child free from any evidences of lymphatic disease will assume 
the mild or supraglottic form. 

It occurs more frequently in boys than in girls, and has been ob- 
served in children from one up to twelve years of age. 

Pathology. -The morbid processes which occur in the laryngeal 
mucous membrane have already been clearly indicated. The no- 
table activity, however, in this process is noticed in that portion 
of the larynx which is below the glottis, where any swelling of the 
part necessarily gives rise to a laryngeal stenosis beneath the glottis. 
It is difficult to account for this symptom by a simple acute ca- 
tarrhal inflammation of the mucous membrane, unaccompanied by 
oedema. But oedema does not occur in this region. Hence, the 
view already advanced seems an exceedingly plausible one: that 
a prominent element of tumefaction lies in the engorgement of the 
lymphatics, which in child life are richly distributed in this region. 

Symptomatology. — The attack may come on independently of any 
involvement of the parts above, but in most instances it occurs coin- 
cidently with an attack of nasal stenosis. The constitutional dis- 
turbance is more marked here than in the milder form of laryngitis ; 
and although the febrile movement rarely exceeds 100° to 101° F., yet 
the systemic involvement is indicated by the marked general malaise. 
The appetite is impaired and the child is dull and listless, and shows 
a lack of interest in its tovs and other amusements. 



618 DISEASES OF THE LARYNX. 

The first symptom which calls attention to the throat, of course, 
is the hoarseness. This in the early stage is shown, not by loss of 
voice, but rather by a certain shrillness or metallic ring to the voice. 
As the inflammatory process progresses, the voice becomes distinctly 
hoarse or completely aphonic. 

A harsh, dry, barking cough sets in very early in the attack, and 
immediately assumes that peculiar tone which we all recognize as be- 
ing croupy in character. That the source of the cough is in the sub- 
glottic tissues is clearly indicated by the fact that even when the 
child is completely aphonic, the cough will still have this same bark- 
ing, metallic ring to it. 

At the beginning of the attack the secretion from the mucous 
membrane is arrested, and the cough is dry and harsh. After the 
first or second day secretion sets in, and the cough is attended with a 
certain amount of expectoration, and is softer. As the subglottic ob- 
struction makes its appearance the cough occurs in paroxysms, and 
is attended with a peculiar crowing inspiration. 

From the very onset of the attack nocturnal exacerbations become 
a prominent and marked feature. These generally come on after the 
child has been asleep for a few hours, when it suddenly starts up, 
either with a paroxysm of croupy coughing, attended with a crowing, 
dyspnceic inspiration, or it wakens with a sudden and violent attack 
of dyspnoea. I am disposed to think that these symptoms are suffi- 
ciently accounted for by the inflammatory swelling, and that muscular 
spasm has probably little if anything to do with the condition. 

It is a noticable fact that even after these symptoms have passed 
away, a certain amount of obstruction is observed in the child's 
breathing. 

While the disease persists, a second or even a third attack may 
occur during the same night, although but one exacerbation is the 
rule. While the attack of laryngitis may last for one or even two 
weeks, these nocturnal exacerbations of dyspnoea rarely occur over 
three or four times. The first attack is usually the most serious in 
character, and on the second and third nights, and perhaps the fourth, 
they recur about the same hour, although with less severity, and 
finally cease. 

Another characteristic of this form of laryngitis is that children 
who once suffer from an attack of this form of disease are very liable 
to have similar attacks with each exposure. Thus, during the damp 
cold seasons of the year a child may have a number of such attacks. 
During the intervals of the winter attacks, as a rule, the voice is apt 
to be thick and husky, and, moreover, the child shows evidence, 
usually, of some chronic catarrhal disease of the upper air passages. 



ACUTE LARYNGITIS IN CHILDREN 619 

Diagnosis. — A laryngoscopic examination, if obtainable, will al- 
ways afford us the best information as regards the special affection 
with which we have to deal. This can and should be made, even in 
small children, much more frequently than is ordinarily attempted. 
If the larynx can be inspected, we find its whole mucous lining red- 
dened and slightly swollen, while on inspiration there can be seen 
below the vocal cords, and intruding itself on the line of vision, the 
rounded masses of subglottic tissue, bellying out beyond the line of 
the true vocal cords, highly injected, and of a deeper red than the 
tissues above, with a tint verging on a purplish hue. They stand out 
in somewhat striking relief, with the vocal cords immediately above 
them, which are of a light pinkish color, or they may be almost nor- 
mal. In many cases the portion of the larynx above the vocal cords 
may present but very slight evidences of inflammatory action. 

In those cases in which a laryngoscopic examination cannot be 
made, the question of diagnosis becomes an exceedingly important 
one, as determined by subjective symptoms. 

An attack of membranous croup is characterized by very much 
greater activity of systemic disturbance, together with a higher grade 
of febrile movement, as shown by the thermometer, than a catarrhal 
inflammation. Moreover, in croup the cough is not so persistent, and 
does not assume the same harsh, barking character. In fact, this 
latter disease comes on somewhat insidiously, the voice becoming 
completely lost early in the attack, and the dyspnoea, moreover, is 
progressive, and not characterized by nocturnal exacerbations. The 
ordinary speaking voice may be apparently lost in both croup and ca- 
tarrhal laryngitis. Its character, however, is shown in the cough, 
which in croup is usually to an extent noiseless, while in the milder 
disease it is, as before shown, harsh and noisy. In those rare in- 
stances in which the croup membrane is located beneath the cords, 
and in which the voice is not completely destroyed, of course the 
differential diagnosis is rendered exceedingly difficult, and must be 
based on objective rather than subjective symptoms. 

In diphtheria we have the marked prostration, general malaise, 
and other evidences of blood poisoning. A bacteriological examina- 
tion of the secretions about the larynx will usually render aid in ex- 
cluding diphtheria. 

The general course of the disease will always be of marked assist- 
ance in establishing a diagnosis. The nocturnal exacerbations and 
diurnal amelioration of symptoms are characteristic of the simple ca- 
tarrhal inflammation of the larynx, whereas the slower but usually 
progressive course of an exudative affection will ordinarily remove 
any obscurity of diagnosis quite early in the progress of the attack. 



620 DISEASES OF THE LARYNX. 

Enlarged cervical glands are the rule in all three forms of disease, 
and hence their presence is of but little diagnostic value. 

A foreign body in the larynx of a child will not infrequently give 
rise to symptoms which cannot be distinguished from a laryngitis. 
In such a case the laryngoscope or digital exploration will alone re- 
veal the true condition with which we have to deal at the onset of the 
attack, although the development of symptoms ought very soon to 
aid the diagnosis. 

Prognosis. — The disease runs its course in from one to two weeks, 
and undergoes spontaneous resolution without involving very serious 
danger to life. The onset of the attack, as we have seen, is character- 
ized by nocturnal exacerbations of a dyspnoeic character, which at the 
time seem somewhat alarming; yet after the second or third recur- 
rence they cease altogether, each attack being less severe than its 
predecessor. A few rare cases, however, have been reported in 
which death occurred. 

Treatment. — We have here to deal with three conditions: first, a 
mild chronic inflammation of the subglottic mucous membrane — the 
result, in the majority of cases, of an engorgement of the lymphatics 
both here and in the parts above, such as the naso-pharynx, giving 
rise to a chronic catarrhal condition; second, an acute inflammation 
of the subglottic membrane, which we regard as a lighting up, as it 
were, of a chronic inflammation, under the influence of exposure to 
cold ; and, third, the nocturnal exacerbation. 

Treatment of the Chronic Condition. — Iodide of iron should be giv- 
en in doses of twenty drops three times a day to a child ten years of 
age, and to a younger child in proportion, either alone or with cod- 
liver oil, and should be persisted in from three to six months. The 
general condition of the child, as well as the local enlargement of the 
lymphatic tissues in the throat and cervical region, should be watched 
with considerable care. If the faucial tonsils are enlarged they 
should be excised. If the lymphatic tissue in the vault of the phar- 
ynx is sufficiently large to cause nasal obstruction, or is the seat of 
excessive secretion, the mass should be removed in the manner pre- 
viously described. 

It is scarcely necessary to add that the child should be placed as 
far as possible in the best hygienic surroundings. 

Treatment of the Acute Process. — As soon as evidences of the 
croupy attack develop, the child should be kept in the nursery, in a 
temperature of 70° or 72° F., and the room properly ventilated; at 
the same time the atmosphere should be kept thoroughly charged 
with moisture. The bowels should be moved by the administration 
of, preferably, a mercurial, in the form of calomel or hydrargyrum 



ACUTE LARYNGITIS IN CHILDREN 621 

euro creta, two to three grains of either to ;i child from five to ten 
years of age. 

Medication to promote a freer secretion from the mucous mem- 
brane may be administered in the form of some of the salts of ammo- 
nia, preferably the muriate. 

If the ammonia is not well tolerated, we may substitute the tinc- 
ture of cubebs, in from three to five drop doses. 

I do not regard the use of cough mixtures in this disease as a mat- 
ter of great importance ; if the stomach is in any way disturbed, they 
should not be exhibited. As a rule, opiates should be avoided. If 
the cough is distressing and persistent, it is liable to aggravate the 
local condition, and the general strength is impaired by loss of sleep ; 
in such a case sedatives become necessary, and we may administer 
the following : 

I£ Acidi hydrocyanici dil., rrt ij. 

Codeinse gr. iss. 

Ammonii muriatis, gr. xvi. 

Aq. laurocerasi, ad 3 ij. 

M. Sig. A teaspoonf ul every two hours as needed. 

The above prescriptions are for a child of seven years; the ingre- 
dients may be given proportionately for younger children. 

If the laryngeal affection is accompanied by a catarrhal condition 
of the nasal passages, local treatment to this region becomes of spe- 
cial importance. If the child is tractable, the passages should be 
sprayed out daily with one of the cleansing solutions already given, 
followed by the application of an astringent. If the child is too 
young to aid the manipulation, we may accomplish much in the di- 
rection of keeping the passages clear by the use of a weak solution of 
cocaine, suspended in an oily menstruum. 

After the fourth or fifth day, when the nocturnal exacerbations 
have ceased, and the secretion in the inflamed part has set in, con- 
finement in the nursery is no longer necessary, and if the weather is 
favorable there is no objection to a short walk in the open air, al- 
though the local applications should be kept up for some days, as 
well as the internal administration of one of the cough mixtures above 
given, but at longer intervals. During the course of the attack the 
diet should be carefully regulated. 

Treatment of the Nocturnal Exacerbation. — The old practice recom- 
mends the administration of an emetic in an attack of false croup, the 
object being to facilitate the expulsion of the accumulated mucus in 
the larynx. This is an awkward practice, and it seems to me an ex- 
ceedingly objectionable one, for it is of importance that -the digestive 
apparatus should be maintained in a healthy condition, and the drugs 



622 DISEASES OF THE LARYNX. 

which are administered for the purpose of emesis are liable to pro- 
duce more than a temporary effect on the mucous membrane of the 
stomach. We have taken the ground that there is no spasmodic mus- 
cular contraction in this disease ; therefore this indication for the pro- 
duction of vomiting is not present. The act of vomiting undoubtedly 
relieves the larynx; this can be accomplished with less disturbance to 
the stomach by simply inserting the finger into the fauces, or, if nec- 
essary, as far as the larynx, and should be resorted to if immediate 
relief becomes urgent. 

The first thing, however, on being called to see a child suffering 
from the dyspnoea of a subglottic laryngitis, is to place the patient in 
a warm bath, its whole body being thoroughly immersed in water at 
a temperature of about 100° F. ; we thus not only get the action of 
the warmth on the skin, but also the benefit of the inhalation of the 
warm vapor. The stimulating action to the skin may be increased by 
dissolving a small amount of mustard in the bath ; this should be 
done with great care, of course, when having to do with the tender 
skin we have in a child. After keeping the child in the bath from 
five to ten minutes, it should be taken out and wrapped in warm 
blankets and put to bed, after which the skin may be dried by the aid 
of a warm towel passed under the flannel. 

These measures failing to relieve, we may give inhalations of hot 
steam, generated by slacking lime or by a spirit lamp. The efficiency 
of steam inhalations is aided, perhaps, if we add to the hot water 
a teaspoonful of fluid extract of lupulin, extract of pinus canadensis, 
oil of turpentine, oil of tar, tincture of benzoin, or a few drops of 
creasote. 

Hot fomentations applied to the cervical region, over the larynx, 
either by means of a sponge or a towel wrung out with hot water, ex- 
ercise a certain amount of derivative action. 

If these measures fail to give relief, an attempt should be made to 
remove the secretions by means of the finger inserted into the larynx ; 
or, if the operator possesses sufficient skill, there is no objection to 
gently passing a small sponge probang over the epiglottis and into 
the laryngeal cavity. This serves not only to dislodge the inspissated 
mucus, but may produce a movement of retching, by which the ob- 
structing mucus may be expelled. 

I know of no drug whose internal administration possesses any 
special virtue in the dyspnceic paroxysm of a subglottic laryngitis, 
unless we except the administration of ten or fifteen minims of ether, 
which may be given when other remedies fail. This may be followed 
by the inhalation of a small amount of the same. The action of this 
drug is probably as a stimulant and expectorant. A somewhat simi- 



ACUTE LARYNGITIS IN CHILDREN. 623 

lar effect may be obtained from the use of nitrite of amyl. Excellent 
results have been obtained by the use of a solution of cocaine and 
menthol, applied by means of a spray. 

All other measures failing to afford relief to the dyspnoea, re- 
sort should be had either to the insertion of an O'Dwyer tube or the 
performance of tracheotomy. If the case is an urgent one, and the 
proper instruments are not at hand for the above operations, a very 
simple measure and one which requires no special manipulative skill 
is the passage of an ordinary flexible catheter through the larnyx and 
into the trachea. As before shown, however, instances in which radi- 
cal measures become necessary are exceedingly rare in subglottic lar- 
yngitis. Not infrequently, however, when first called to a case of 
this sort, it is by no means possible to be absolutely sure of one's 
diagnosis, and we are oftentimes compelled to treat symptoms as 
they arise rather than a recognized diseased condition. 



CHAPTER LXXVIII. 

CHRONIC LAKYNGITIS. 

Under this general term we describe three affections of the laryn- 
geal mucous membrane, which, while they constitute distinct diseases 
from a clinical point of view, are grouped together because they are 
all essentially catarrhal processes. They are: First, chronic catar- 
rhal laryngitis; second, chronic subglottic laryngitis; and third y 
trachoma of the larynx, or chorditis tuberosa. 

Chronic Catarrhal Laryngitis. 

By this term is meant a chronic catarrhal inflammation of the mu- 
cous membrane lining the laryngeal cavity. We adhere to the classi- 
fication of disease which has been adopted throughout this work, and 
avoid the confusion which has crept into much of our literature on 
throat diseases. 

The older writers describe three forms of chronic laryngitis — the 
syphilitic, tuberculous, and catarrhal — an error which is still followed 
by many who discuss syphilitic and tuberculous disease of the larynx 
under the general heading of "chronic laryngitis," and others who 
write of syphilitic and tuberculous laryngitis in connection with 
chronic catarrhal laryngitis. The essential morbid processes which 
constitute syphilis and tuberculosis are not inflammatory in character. 
Moreover, syphilis and tuberculosis are not to be regarded as the 
causes of a chronic catarrhal laryngitis. I think it a far better no- 
menclature to adopt the terms " syphilis of the larynx" and " tuber- 
culosis of the larynx," and to restrict the use of the termination itis to 
the designation of an inflammation of a purely catarrhal character; 
and in using the term "chronic laryngitis," we therefore specify that 
form of disease of the laryngeal mucous membrane which is charac- 
terized by a chronic inflammation of a purely catarrhal nature. 

This form of larnygeal disease has been greatly overestimated; 
many persons undoubtedly are affected with it and yet experience lit- 
tle discomfort. To singers and public speakers, however, it is a dis- 
ease of no little gravity. 



CHRONIC LARYNGITIS. 625 

Etiology. — It is doubtful if a simple uncomplicated chronic laryn- 
gitis is ever a primary disease. Certainly no case has come under 
my own observation in which the development of the morbid process 
could not be traced directly to some diseased condition of the air pas- 
sages above. It may result from a chronic naso-pharyngitis, hyper- 
trophy of the lymphatic tissue in the vault of the pharynx, or from 
nasal stenosis as the result of hjqjertrophic rhinitis, deflection of the 
septum, the presence of tumors, or other obstructive lesion ; it also 
may arise from an atrophic rhinitis. 

If the lesion in the nose is obstructive, nasal respiration is inter- 
fered with and its important respiratory function to an extent 
affected ; the current of inspired air reaches the larynx through the 
mouth ; it is not warmed and cleansed as it should be in its passage 
through the nose, and hence leads to the development of a mild 
chronic inflammatory process in the laryngeal membrane. It is easy 
to understand how, in a similar way, the presence of hypertrophied 
pharyngeal or faucial tonsils may interfere with normal respiration 
and lead to a catarrhal disturbance in the larynx. While a chronic 
naso-pharyngitis does not necessarily give rise to any obstruction to 
the respiratory current, yet as a matter of clinical observation it is 
one of the most frequent causes of a chronic laryngitis. Why this 
should be so is not entirely clear ; it certainly is not due to the secre- 
tions from the pharyngeal vault making their way into the larynx. 
It is probably the result of the constant hawking and vigorous efforts 
at clearing the throat which the lodgement of the thick and inspis- 
sated mucus in the fauces entails. 

Between the ages of five and fifteen, the prevailing type of catar- 
rhal disease is dependent upon some involvement of the lymphatic 
tissues ; hence, at this period of life, a chronic laryngitis is in most 
instances the result of hypertrophy of the pharyngeal tonsil. Be- 
tween the ages of fifteen and forty we find catarrhal diseases depen- 
dent upon some obstructive lesion in the nasal passages ; hence, at 
this period, a chronic laryngeal disorder in the majority of in- 
stances is the result of a hypertrophic rhinitis or a deflected septum, 
or both. After the age of forty, the most common form of catarrhal 
disease is the result of some diseased condition of the naso-pharynx ; 
at this period of life, then, the source of a laryngeal disorder is to be 
sought in a chronic naso-pharyngeal catarrh, for it is to be borne in 
mind that if a hypertrophic rhinitis, the result of a deflected septum, 
has previously existed, the membrane in later life undergoes a shrink- 
ing and to a certain extent ceases to be a source of disturbance. 

While decidedly of the opinion that in the very large majority of 
instances the cause of the disease is to be sought in the passages 
40 



626 DISEASES OF THE LARYNX. 

above, I ani not ready to assert that this is the invariable rule, in that 
it would scarcely be justifiable to state that local causes may not exert 
a directly active influence in developing the disease ; thus in public 
speakers, prolonged or excessive or perhaps too vigorous use of the 
voice may undoubtedly lead to a vascular turgescence which may in- 
duce a chronic inflammatory process. In the same way a singer, by 
too prolonged or too vigorous practice, or by the use of improper or 
incorrect methods of tone formation, may set up morbid changes in 
the membrane. 

We are told that those occupations which involve the inhalation 
of a vitiated or dust-laden atmosphere, such as that of millers, car- 
penters, coal heavers, stone cutters, workers in tobacco, mill opera- 
tives, etc., have a marked influence in producing a laryngeal inflam- 
mation; this may be true, but it seems to me the statement is 
somewhat overdrawn. The mucous membrane in the upper air tract 
is very tolerant, and nature has provided an admirable method for 
cleansing the respired air in such a way that but little of its impuri- 
ties reach the larynx. The prolonged use of the voice in public 
speaking or singing is liable to involve a certain amount of mouth 
breathing. One who is well trained always closes the mouth during 
inspiration, or recovery as it is called. While, therefore, the vitiated 
atmosphere may have something to do with the vocal impairment 
above alluded to, in most instances, probably, the improper methods 
of recovery are mainly at fault. 

The moderate use of alcohol, probably, has but little influence on 
the larynx, while its excessive use is usually attended by a diffuse 
general inflammation, through both the naso-pharynx and the oro- 
pharynx, this condition setting up eventually a chronic laryngeal 
catarrh. The influence of tobacco is generally dependent upon the 
individual temperament. Most smokers indulge in the habit with 
impunity ; in certain individuals, however, any slight excess is almost 
invariably followed by an attack of acute pharyngitis or nasopharyn- 
gitis, and a resultant laryngeal hyperemia. 

Ingals has reported a series of cases of the disease which were 
dependent upon the rheumatic habit. 

All catarrhal diseases of the upper air tract are more common in 
males than females, and the same law applies to the larynx. It 
occurs at all ages, although it is most frequently met with in adult 
life and middle age. 

Pathology. — The morbid changes which occur in the mucous 
lining of the larynx, in an ordinary case of catarrhal inflammation, 
present no points of special interest. The changes in the vocal cords 
themselves consist mainly in increased vascularity, hyperplastic 



CHRONIC LARYNGITIS. 627 

changes being exceedingly rare in the mucous membrane of the cords. 
Kheiner describes a distinct form of chronic laryngitis under the 
name of "pachydermia laryngis," in which the hyperplastic changes 
are confined mainly to the posterior portion of the vocal cord, at its 
junction with the vocal process. These changes consist in an aug- 
mentation both of the epithelial and connective-tissue elements of the 
membrane, the epithelium being superimposed upon and distinct 
from the papillary layer beneath, in contradistinction to malignant 
disease, in which the epithelium burrows into and forms nests in the 
mucosa proper. 

In certain rare instances, dilated and tortuous veins are observed 
coursing in the superficial layers of the mucous membrane covering 
the ventricular bands, the ary -epiglottic folds, or the face of the epi- 
glottis. Mackenzie gives to this condition the name of " phlebectasis 
laryngea," regarding it as an independent affection resulting from 
strain or other cause. I am disposed, however, to agree with Du- 
chek in regarding it as an adventitious feature of catarrhal inflamma- 
tion. 

Mackenzie, Gordon Holmes, and others describe a form of the 
disease under the name of "chronic glandular laryngitis," in which 
the inflammatory process confines itself mainly to the racemose 
glands, and which they regard as analogous to and in many cases a 
downward extension of a follicular pharyngitis or " clergyman's sore 
throat." 

I do not recall ever having seen a case of inflammation of the 
mucous membrane of the upper air passages in which the morbid 
process confined itself to, or was specially active in, the muciparous 
glands, but I am disposed to think that, when the membrane pre- 
sents the gross appearances of this, it is the lymphatic bodies that 
are the seat of morbid action, rather than the secreting glands. 

Symptomatology. — The prominent feature, of course, of the dis- 
ease consists in an impairment of function in phonation. 

A notable indication of the weakness of function is shown by the 
fact that, in the morning, after the mucus which has accumulated in 
the air passages during the night has been removed, the voice is 
comparatively clear. As the result of the ordinary use which daily 
duties involve, the voice is liable to get weak and husky later in the 
day. In singers and public speakers, and in those whose occupation 
calls for the higher powers of the larynx, this impairment of vocal 
function is very noticeable. Both in singing and public speaking, a 
moderate use of the voice results in a tired, sore feeling in the larynx, 
which very soon compels the individual to abandon further effort. 
The feeling of weariness and distress which results is of course due 



628 DISEASES OF THE LARYNX. 

to the fact that the laryngeal muscles are brought into play under 
exceedingly unfavorable circumstances. They are not only hampered 
by the inflammatory process in the mucous membrane covering them, 
but the muscular effort required in effecting a proper tension of the 
cords is very markedly increased. 

Diagnosis. — Ordinarily, the disease should be easily recognized 
by subjective symptoms. The impairment of voice establishes a dis- 
eased condition of the laryngeal membrane, while the absence of 
cough is a fairly clear indication that the parts below are not in- 
volved. A definite diagnosis, however, of course, can be established 
only by the laryngoscopic examination, as revealing the absence of 
tumors, paralysis, and ulcerative or exudative affections. 

"When seen by the laryngeal mirror, the mucous membrane lining 
the larynx will present the ordinary appearances of a chronic inflam- 
matory process. 

A simple, uncomplicated laryngitis, I believe, in all cases shows 
an evenly diffused and fairly symmetrical discoloration in both sides 
of the larynx. If this hyperemia is confined to one side of the 
larynx, I should regard it as an exceedingly suspicious circum- 
stance, and one which requires the most careful investigation with 
reference to the possible existence of a more serious affection, such 
as ulceration, a benign growth, or, more especially, malignant dis- 
ease, unless a foreign body be present, or some other obvious cause. 

The mucous membrane covering the cords, as we know, is com- 
posed of epithelial cells, superimposed directly upon the fibrous tis- 
sue of the vocal band, with the interposition of a somewhat scanty 
network of blood-vessels. Hence, in this region, the chronic inflam- 
mation is shown by a somewhat grayish discoloration of the parts, 
which stand out in contrast to the red, purplish color of the ventricu- 
lar bands and other portions of the larynx, which are the seat of 
morbid changes. Moreover, the cords are slightly swollen, and pre- 
sent certain irregularities, not only on the surface, but on the edges, 
the result of a somewhat irregular epithelial proliferation. This is 
apt to be most marked in their posterior portion, and especially in 
the neighborhood of the vocal processes of the ary tenoicl cartilages ; 
whereas the vascular hyperemia gives ordinarily a grayish look to 
the cord. 

Additional information is obtained by the movements of the glottis 
in phonation. Adduction of the cords is not accomplished with that 
perfection and precision which are observable in health. This is 
especially noticeable when the arytenoid commissure is swollen, and 
when there is marked epithelial hyperplasia at its anterior face, 
constituting an almost wart-like appearance in this neighborhood. 



CHRONIC LARYNGITIS. 629 

The epithelial hypertrophy on the anterior face of the arytenoid 
commissure forms minute, wart-like eminences, which project toward 
the anterior wall of the larynx in such a way that, when the glottis 
is closed, the membrane in this region looks as if it were traversed 
by small fissures. I think this is the condition which has led Stoerk 
to believe that fissures really occur in the membrane at this point, 
and to which he gives the name of "fissurae mucosae." 

Prognosis. — The disease runs no definite course, and its symp- 
toms persist as long as the morbid affections of the passages above, 
which are responsible for it, endure. While, therefore, it shows no 
tendencies to improve, there is, on the other hand, no marked dis- 
position to grow worse. After the symptoms of vocal impairment 
have once developed, they persist usually in much the same degree, 
unless aggravated by special circumstances, such as improper use of 
or straining the voice. The principal changes which occur in the 
course of the disease consist in the repeated exacerbations of the 
inflammatory process, under the form of an acute laryngitis, due to 
exposure to cold or other causes. 

The main point of interest, in the discussion of prognosis, has to 
do with the possibility of a simple catarrhal process in this region, 
developing into a more serious trouble, such as a benign or malig- 
nant tumor or tuberculosis. I believe that a catarrhal inflamma- 
tion must be regarded as an active factor in the causation of a 
laryngeal neoplasm, for while the active hyperemia which the laryn- 
goscope reveals in the larynx, in a case of neoplasm, may be the 
result of the growth, the clinical history of the patient usually teaches 
us that a chronic laryngitis, in connection with a diseased condition 
of the air passages above, existed long before the development of the 
tumor. 

As regards malignant disease in the larynx, I do not think that 
either our knowledge of pathological processes or the teachings of 
clinical investigation lend any support whatever to the view that a 
simple catarrhal process in the larynx is either an active or a pre- 
disposing cause of a cancerous growth. 

As to tuberculosis, I regard the two diseases as entirely separate 
and distinct, and I know of no clinical observation which justifies us 
in regarding tuberculous disease as even a remote danger to a simple 
catarrhal process. 

The only further element in prognosis which requires considera- 
tion is that of the curability of the catarrhal disease. Many writers 
assert that, even after the disappearance of the morbid condition 
under proper treatment, the voice is liable to remain weak and hoarse. 
This I should regard as sufficient evidence that the disease had not 



630 DISEASES OF THE LARYNX. 

been cured; and by a cure I mean, not only of the local morbid proc- 
ess, but of the more important conditions in the air passages above 
which have been active in its causation. In the present state of local 
and general therapeutics, I believe we are fully competent to remove 
diseased conditions not only of the larynx, but of the parts above ; 
and when such has been accomplished the voice should be restored 
to its fullest functions. 

Treatment. — It has already been asserted, with a certain degree 
of emphasis, that a chronic laryngitis is not a primary but a sec- 
ondary disease, dependent upon some diseased condition of the parts 
above. The first and most prominent indication, therefore, for its 
treatment consists in the thorough restoration of the passages above 
to a condition of health. If an hypertrophic rhinitis exists, it should 
be treated after the manner already described in the chapter devoted 
to that subject. The same is to be said in regard to a deflected sep- 
tum, chronic naso-pharyngeal catarrh, hypertrophied pharyngeal, 
faucial, and lingual tonsils, etc. If an atrophic rhinitis exists, this 
we know to be an incurable disease, and yet, as we have already 
shown in the chapter on that subject, it is one which can be brought 
practically under control so far to obviate to a very great extent 
the influence of the disease upon the parts below ; hence, even when 
a laryngitis is dependent upon this condition, we may hope by active 
measures, both at the hands of the physician and the patient, to 
bring the resultant laryngeal disease under control. 

The question of the value of local applications to the larynx, 
together with that of the various methods by which they are made, 
has always been a subject of considerable discussion. As before 
stated, the prominent indication in the treatment of the laryngeal 
disease lies in the treatment of the parts above; and yet very much 
is undoubtedly gained by the direct local treatment. This requires 
no very special skill of manipulation, and can be easily and effec- 
tively made in the hands of one not specially trained in laryngoscopic 
methods. A brush, sponge, probang, or instrument of this sort, I 
think, should never be applied directly to the laryngeal cavity in a 
simple catarrhal inflammation, except at the hands of a thoroughly 
well-trained manipulator. My preference is very decidedly in favor 
of some form of spray producer, either that worked by compressed 
air or some simple hand-ball instrument. 

I believe that in the treatment of a simple catarrhal process, the 
milder astringents are far more efficient than the stronger ones. The 
indications for caustics or destructive agents in this disease do not 
exist. The morbid process is confined mainly to the superficial tis- 
sues, and hypertrophic conditions which require destructive measures 



CHRONIC LARYNGITIS. 631 

are exceedingly rare. Of all local astringents, I regard nitrate of 
silver as probably the best. 

As a rule, I think a ten-grain solution is of sufficient strength to 
accomplish all that is necessary, although in some instances a twenty- 
grain solution may be used. Still, regarding this drug as most valu- 
able in the majority of instances, a change is occasionally desirable, 
when we may substitute for silver other drugs of similar action. 
Thus, in the order of preference, we may use : 



Argenti nitras, 
Zinci sulphas, . 

" chloridum, 
Liquor ferri persulphatis, 
Cupri sulphas, 



gr. 5 to 20 to the oz. 

5 " 20 

2"6 
min. 10 " 30 

gr. 3 " 10 



I have never seen any special good accomplished in this disease 
by the vegetable astringents, such as tannic and gallic acid, and 
drugs of this order, or hj iodine and its preparations, carbolic acid, 
creasote, etc. 

Cold inhalations, by means of the globe inhalers, of astringent 
remedies, such as those above given, although much reduced in 
strength, are often attended with a certain amount of comfort and 
relief to the patient; and yet I think the value of this method is 
largely in those cases in which the catarrhal inflammation has ex- 
tended somewhat into the bronchi, giving rise to cough and expecto- 
ration. The inhalation of nascent muriate of ammonia by the Lewin 
apparatus is of use mainly in those cases which are dependent on a 
naso- pharyngeal catarrh, the action of the ammonia being to stimu- 
late the membrane, producing a freer secretion and thereby facilitat- 
ing expectoration, with a consequent relief to the laryngeal disorder. 
The direct effect of ammonia on the laryngeal membrane is probably 
very slight. Inhalations of astringents by means of the steam ato- 
mizer are, I think, objectionable, in that the hot steam is liable to 
cause a certain amount of relaxation of the parts, while at the same 
time the astringent is so far diluted as to exert very little direct action 
on the laryngeal membrane. 

We have already discussed the question of throat lozenges in a 
previous chapter. 

It would seem, then, that our topical measures for the treatment 
of this disease are practically confined to certain astringent solutions 
applied directly to the larynx by means of the atomizer. Our thera- 
peutic measures thus become exceedingly simple in character. 

These direct applications to the larynx should be made somewhat 
according to circumstances. While condemning the use of caustics 
in the larynx, on the ground that destructive action is not desirable 



632 DISEASES OF THE LARYNX. 

in the majority of cases, yet we occasionally meet with instances of 
pachydermia in which we have a notable degree of hypertrophy at 
the posterior insertion of the cords and the anterior face of the com- 
missure, giving rise to what appears almost like warty excrescences 
in this region. For this condition, a caustic application becomes 
necessary ; the special agent used is perhaps of not so much impor- 
tance as the nicetj^ and dexterity with which it is applied, for it is 
desirable that the application should confine itself closely to the dis- 
eased tissue. My own preference is in favor of chromic acid, fused 
on the end of a probe, and applied with a properly hooded porte- 
caustique ; although probably the solid stick of nitrate of silver, or 
acetic acid, might answer an equally good purpose. 

There is one element of treatment which becomes of exceeding 
great importance in treating a chronic laryngitis in a singer or public 
speaker, and that is as perfect rest to the voice as is compatible with 
occupation and surroundings. An important element in the success- 
ful treatment of all cases of catarrhal disease is in the enforcement of 
certain hygienic rules in regard to the proper clothing of the body, 
the use of the bath, etc. These have already been fully discussed in 
the chapter on taking cold. 

The habitual use of alcohol probably acts primarily on the diges- 
tive apparatus, and secondarily on the upper air tract. The moderate 
use of wines or alcoholic beverages is probably not directly injurious 
to the vocal organ; hence, I think it is not always demanded of us, 
or even wise, to forbid their use in all cases. The influence of the 
use of tobacco on chronic laryngeal catarrh is to be estimated in each 
individual case. Excessive use of tobacco is undoubtedly injurious ; 
its moderate use probably has but little effect on the air tract. 

Chkonic Subglottic Lakyngitis. 

This fortunately somewhat rare form of chronic laryngitis is one 
in which the morbid process develops mainly in the subglottic por- 
tion of the larynx, resulting in certain hypertrophic changes whereby 
the breathing space is so far encroached upon as to result in the 
development, not infrequently, of symptoms of a grave character. 

Etiology. — The origin of the disease seems to rest in considerable 
obscurity ; it occurs more frequently in females than males, and is 
met with in the earlier periods of life, usually between the ages of 
fifteen and twenty -five. 

The lymphatic habit we believe may be a ver} r important active 
predisposing and perhaps direct cause of this form of laryngitis as 
met with in adult life. In the only cases of the affection which have 



CHRONIC LARYNGITIS. 633 

come under my own observation, the lymphatic habit, as evidenced 
by enlarged faucial or lingual tonsils, seemed to exercise a notable 
influence upon the development of the disease, as shown by the fact 
that the local condition of the larynx was markedly ameliorated by 
the removal of the hypertrophied lymphatic tissue in the parts above, 
and by the administration of full doses of the iodide of iron to correct 
the systemic condition. Typhus and typhoid fever may result in 
this form of laryngeal disorder, although they are more liable to give 
rise to a perichondritis; tuberculosis and perichondritis constitute 
morbid processes in which there is no relation either direct or in- 
direct to lymphatic diseases ; the same can be said of syphilis. As 
regards rhino-scleroma, it is probable that it may exert a causative 
influence in the development of subglottic laryngitis. That a simple 
idiopathic inflammatory process in this region, which is not influ- 
enced by any pronounced systemic condition, may give rise to a 
chronic subglottic laryngitis cannot be questioned, and yet I think 
in the large majority of instances we must look for some diathetic 
state, to explain the fact of a simple catarrhal process resulting in 
such marked hypertrophy as to seriously encroach on the breathing 
space. 

Pathology. — Few post-mortem examinations have been made in 
cases of this affection, hence suggestions in regard to the true path- 
ological changes which occur can only be speculative ; and we content 
ourselves, therefore, with the views expressed above in discussing 
the etiology of the disease. 

Symptomatology. — The onset of the disease is somewhat insidi- 
ous, and is marked by a slowly developing, but progressive impair- 
ment of voice, which finally results in more or less complete aphonia. 
Cough, with expectoration, is ordinarily not present. As the swell- 
ing pr ogresses, dyspnoea sets in, as evidenced both by inspiratory 
and expiratory stridor ; the dyspnoea is not infrequently aggravated 
by exertion. At this stage of the disease, phonation is practically 
abolished, and the symptoms consist now in a slow but surely pro- 
gressive increase of the difficulty in breathing. Repeated exacerba- 
tions of mild acute inflammation become a prominent symptom, 
under the influence of which the dyspnoea is temporarily increased ; 
there is liable to be an increased amount of secretion, in consequence 
of which a harsh, metallic, ringing, or barking cough, which is apt to 
be persistent and oftentimes distressing to the patient, becomes a 
prominent symptom. The acute process subsides in a few days or a 
week, but the chronic process is progressive, until finally the en- 
croachment on the air passages demands relief by tracheotomy, unless 
other and simpler measures have availed. Pain is occasionally 



634 



DISEASES OF THE LARYNX. 



present, especially during the exacerbations, although this symp- 
tom is more characteristic of perichondritis than of subglottic 
laryngitis. 

Diagnosis. — An inspection of the parts by the laryngoscope will 
show in the supraglottic portion of the larynx the ordinary appear- 
ances of chronic laryngeal catarrh or possibly no deviation from the 
normal standard, unless in the true cords, which ordinarily present 
a thick and somewhat rounded appearance, with a grayish, discolored 
aspect. Immediately below the edge of the cords there will be seen, 
bulging into the breathing-space, from either side, two rounded and 

symmetrically swollen masses of a 
grayish appearance, or in rare in- 
stances presenting the dark reddish 
color of a chronic inflammation 
(see Fig. 130). These tumefactions 
present an appearance of density 
and solidity, which give the con- 
dition the aspect of a neoplasm. 
The extent of hypertrophy neces- 
sarily affords a mechanical obstacle 
to the movements of the vocal cords 
in phonation and respiration. If 
the tumefaction is very marked, the 
anterior portions are in contact, 
of an abnormal adhesion, or this 




Fig. 130.— Chronic Subglottic Laryngitis. 



the 



appearance 



presenting 

coalescence may present posteriorly, or both conditions may 

exist. 

The tissues are apt to present a dry and somewhat glazed aspect. 
If the parts are seen during an exacerbation, the appearances are 
those ordinarily seen in acute inflammation, unless a certain amount 
of oedema supervenes, in which case we have the bluish-white, semi- 
transparent appearance characteristic of that process. 

The clinical history of the disease is closely allied to that of peri- 
chondritis; in this latter disease, however, the tumefaction is not 
only irregular in outline, but asymmetrical, and invariably unilate- 
ral, whereas the disease in question is always bilateral and presents 
evenly rounded and entirely symmetrical tumefactions. 

Pkognosis. — In a few instances, in which the disease followed ty- 
phus fever, the symptoms developed very rapidly, and required trache- 
otomy at the end of from one to two months. In the majority of in- 
stances, however, as we have seen, the direct cause of the disease is 
not apparent. In such cases we have a slower and more insidious 
developmeDt, and the severe dyspnceic symptoms do not appear 



CHRONIC LARYNGITIS. 635 

until from nine to eighteen months after the first manifestations of 
the affection. 

I know of no case in which spontaneous resolution has occurred. 
It would seem that in the majority of cases the disease is incurable, 
while in a certain proportion of cases active remedial measures have 
served permanently to eradicate it. 

Tkeatment. — As will be easily gathered from what has been said, 
we have practically to deal with an organic stricture of the larynx, in 
which the point of narrowing is in the subglottic tissues. 

In the majority of instances, either as the result of the failure of 
local measures to arrest the disease, or in consequence of its unim- 
peded development, tracheotomy becomes imperative. 

No topical applications seem to be of any avail in promoting reso- 
lution of the thickened tissue. 

Gerhardt scarified the tissues after the tracheal tube had been in- 
serted, with apparently some favorable result, and yet not sufficient 
to permit of the permanent removal of the tube. Bergmann did a 
thyrotomy, and successfully destroyed the thickened tissue by the 
Paquelin cautery; while Sokolowski met with an equal success by 
excising the hypertrophied masses after opening the larynx. 

Dilating bougies passed directly through the point of stenosis 
would, from late reports, appear to give favorable results. 

In place, however, of using the solid bougie, a hollow dilator is 
used, as in this manner breathing is less interfered with, and the in- 
strument may remain in situ for a longer time. 

No case of this disease has come within my own observation in 
which dyspnoea became a distressing symptom. In those cases, how- 
ever, which have been under my observation, evidences of the lym- 
phatic habit were so prominent as to warrant the administration of 
iodine, which was given apparently with excellent results. The 
suggestion would therefore seem to be justifiable that the efficacy of 
some preparation of iodine should be thoroughly tried in these 
cases, especially if seen during early life or before grave dyspnoeic 
symptoms have supervened. The iodide of iron should be adminis- 
tered rather than any other form of the drug. 

Trachoma of the Larynx, or Chorditis Tuberosa. 

This is an affection of the laryngeal mucous membrane which con- 
sists in the development on one or both of the vocal cords of a small 
rounded nodule or tuberosity. It is occasionally classified under the 
head of neoplasms. From a clinical point of view, however, it seems 
more appropriate to consider it as one of the forms of laryngitis, in 



636 



DISEASES OF THE LARYNX. 



that the origin of the disease is invariably to be sought in a chronic 
inflammation of the laryngeal mucous membrane. On the vocal cord, 
usually midway between the vocal process and its anterior insertion 
is a small, rounded projection, which is sessile in character, and 
stands out from the free border of the cord, showing itself distinctly 
in profile on the laryngoscopic examination (see Fig. 131). It ap- 
X>ears to be practically a tumefaction of the fibrous tissue of the cord, 
protruding from it, the same uniform color showing through the very 
thin mucous membrane. After it has developed it seems to remain 
stationary, and shows no tendency to increase in size. It may de- 
velop on a single cord, to be subse- 
quently followed by a similar proc- 
ess on the opposite cord in exactly 
the same situation, or it may de- 
velop on both cords simultaneously. 
In my experience it occurs only as 
the result of an attempt to use the 
highest powers of the larynx when 
it is in a condition of chronic 
catarrhal inflammation, to exert an 
effort which can be accomplished 
with impunity only when the larynx 
is in a state of perfect health. In 
the lower and middle register of 
the singing voice, the notes are produced by vibrations of the 
vocal cords in their full length, the higher pitch being secured with 
each additional note by greater tension of the vocal cords. When 
we have reached the top or middle register the vocal cords seem to 
have reached their limit of tension; hence, still higher notes must be 
produced by shortening the vibrating cords. This is accomplished 
by gradually shortening the chink of the glottis by bringing into 
apposition the edges of the posterior portion of the cord until, finally, 
in the production of the upper notes of the head register the vibra- 
tions are confined to the anterior third of the vocal cords. How 
this was accomplished was always somewhat of a mystery until 
Madame Seiler showed the existence of a small, slender, rod-like 
fibroid cartilage embedded in the vocal cord and extending from the 
vocal process to the junction of the middle and anterior third of the 
cord. It is by means of this fibro-cartilage that the posterior portion 
of the cords are held in apposition, and the chink of the glottis in 
the high notes of the register is thus composed only of the anterior 
third of the two cords. It is at the posterior termination of this 
chink that these nodes or singer's nodes appear; hence, since we 




Fig. 131.— Trachoma of Eight Vocal Cord. 



CHRONIC LARYNGITIS. 637 

know that the very highest muscular powers of the larynx are 
required for the production of these high notes, I am disposed 
to think that these nodes are the result of this excessive effort in 
holding the posterior portions of the cords in apposition during the 
production of these high notes in a larynx which is the seat of an 
inflammatory process. As the vocal cord has no muciparous glands, 
the nodes cannot be due to hypertrophy of the gland structure. The 
pathological lesion is probably somewhat analogous to pachydermia, 
with the addition of a certain amount of connective-tissue hyper- 
trophy. Wedel has also found a number of nuclei embedded in the 
tissues, and their existence would seem to indicate an inflammatory 
process. 

The symptoms to which the condition gives rise are chiefly func- 
tional, and consist in hoarseness or aphonia, resulting from a me- 
chanical interference with the free vibration and proper approxima- 
tion of the cords. This hoarseness is especially noticeable in the 
singing voice, and the taking of high notes is rendered almost impos- 
sible. 

The diagnosis is easily made by a laryngoscopic examination, 
the mirror revealing, on one or both cords, a small, whitish-gray 
nodule, always in the same location and especially prominent on 
attempted phonation. 

The treatment consists mainly in topical applications to correct 
the chronic laryngitis which accompanies the affection. If the affec- 
tion has lasted but a short time, or, in other words, the hyperplastic 
tissue is not organized, complete resolution may sometimes be 
secured by applying a strong solution of nitrate of silver three times 
a week at least, or better still, every day, using cotton wrapped on 
a bent applicator. The voice should not be used at all in singing, 
and as little as possible in conversation. If this measure fails to 
give relief, the larynx should be anaesthetized by a ten or twenty per 
cent solution of cocaine and the galvano-cautery applied by means 
of a fine-pointed electrode, just touching the point of the nodule while 
the cords are in a state of approximation. The current should be 
turned on and then almost immediately shut off again, to avoid risk 
of possible destruction of tissue. Too much importance cannot be 
attached to thoroughly eradicating the cause of the chronic catarrhal 
process. I do not think singers' nodes develop in a healthy larynx, 
and, furthermore, I do not think a catarrhal laryngitis exists except 
as the result of disease above ; hence if the nodes are destroyed they 
are liable to return again unless the exciting cause has been thor- 
oughly abolished. 



CHAPTER LXXIX. 
LAEYNGITIS SICCA. 

This is a name given to that form of catarrhal inflammation of the 
larynx which is characterized by a deficiency of secretion and the 
formation of crusts, which lodge upon and adhere to the laryngeal 
mucous membrane. This condition was first referred to by Ruhle. 

Etiology. — I do not find a case in which it did not accompany a 
diseased condition of some of the parts above; in a majority of cases 
it was in connection with an atrophic rhinitis; in others with an 
atrophic condition of the naso-pharynx or oro-pharynx. This would 
seem to indicate that the laryngeal affection is symptomatic, and yet 
when we consider the frequency of an atrophic process in the nasal 
passages, and the infrequency of a laryngitis sicca, we are led to the 
conclusion that there must be some diseased condition in the laryn- 
geal mucous membrane. 

Massei and others suggest that the atrophic process extends from 
the parts above to the larynx. We have already stated, with con- 
siderable emphasis, that catarrhal processes do not extend by con- 
tinuity of tissue from the naso-pharynx into the larynx. I regard 
this as an almost invariable rule. 

The direct cause of the disease in question, therefore, is probably 
in some morbid condition of the laryngeal mucous membrane, under 
the influence of which the function of the muciparous glands is either 
hampered or completely destroyed. 

The symptoms are much aggravated by the inhalation of an 
abnormally dryatmosphere, as also occurs in cases of atrophic rhini- 
tis when the turbinated bodies have been destroyed, and also by 
mouth-breathing. 

Pathology. — The investigations of Luc, who has demonstrated in 
the crusts Loewenberg's ozaena diplococcus, would seem to show that 
the changes are similar to those which occur in atrophic rhinitis. 
This we regard, as previously stated, as an accompaniment rather 
than the cause of the morbid process. 

That the condition is due to local changes, and is not entirely 
symptomatic of a diseased condition of the parts above, is shown by 



LARYNGITIS SICCA. 



639 



the fact that the crust formation does not occur in the whole cavity 
of the larnyx, but only in the subglottic portion. The disease has 
been described as a " laryngotracheal ozsena," indicating involvement 
of the trachea. Crusts may be found extending below the cricoid 
ring, but are probably masses of inspissated mucus, whose source is 
the subglottic larynx. 

Symptomatology. — During waking hours the normal movements 
of the glottis serve to keep the parts comparatively free from crust 
accumulation. During the night, however, they augment to such an 
extent that the symptoms on waking in the morning may be of a 
somewhat distressing character. They give rise to a more or less 
complete loss of voice with a feel- 
ing of irritation, and violent efforts 
to clear the throat. If the crust 
accumulation is large, dyspnoea 
may be present in a very marked 
degree. The voluntary efforts at 
clearing the part in the morning 
serve to give great relief at the time, 
although the cough, with the im- 
pairment of voice and sense of dis- 
comfort, generally persists more or 
less throughout the day. 

The masses when expelled pre- 
sent much the same greenish -yellow 
appearance as those which are discharged in atrophic rhinitis, but 
are smaller. 

Fetid breath is a constant symptom of the disease. The source 
of the fetor can as a rule be located, it being detected in the oral ex- 
piration, being thus distinguished from the fetor of atrophic rhinitis, 
which is more marked in the nasal expiration. 

The mucous membrane beneath the crusts is usually somewhat 
eroded. 

Diagnosis. — The subjective symptoms are so prominent as to in- 
dicate with a fair degree of accurac}^ the character and location of the 
diseased process. A certain diagnosis, however, can be made only 
by the use of the laryngoscope, which will reveal the greenish-gray 
crusts lodged upon and adhering to the subglottic portion of the 
mucous membrane and projecting into the lumen of the respiratory 
tract. In rare instances, thin flocculi of inspissated muco-pus or a 
dry crust may be seen above the vocal cords (see Fig. 132), and ad- 
herent to the ventricular bands or to the arytenoid commissure. In 
the large majority of instances, however, the disease confines itself to 




Fig. 132.— Crust Lying in the Ventricle in 
Laryngitis Sicca. 



640 DISEASES OF THE LARYNX. 

the subglottic portion, and when it is seen above the cords the activ- 
ity of the morbid process is much less. 

If the crusts have been expelled by voluntary effort at the time of 
examination, the small, yellowish-gray flocculi will be seen here and 
there adherent to the mucous surfaces, while beneath them the sub- 
glottic membrane, if visible, will show evidences of an inflammatory 
process. 

Coukse and Prognosis. — The disease is essentially chronic, and 
shows no tendency to improve except under treatment. 

If we are correct in the view already taken, that the essential le- 
sion consists in an atrophy of the glandular structures or the secret- 
ing apparatus of the mucous membrane, it would seem that, unless 
attacked comparatively early in its progress, the disease is somewhat 
intractable. And yet the atrophic process is not the only element to 
be considered. If we have the laryngeal disease occurring in con- 
nection with an atrophic rhinitis which is incurable, we can hope 
only to ameliorate the symptoms. If, however, we meet with it in 
connection with a curable affection of the nasal passages, the progno- 
sis is favorable. 

Treatment. — The first and most important indication for treat- 
ment is to establish a healthy condition in the mucous membrane of 
the upper air tract. If an obstruction exists in the nasal passages, 
either from a deflected septum, hypertrophic rhinitis, the existence 
of tumors, or from any other cause, this should be removed. If an 
atrophic rhinitis exists, our efforts should be directed toward estab- 
lishing as healthy a condition of the nasal passages as our therapeu- 
tic resources are capable of, in the manner already discussed in the 
chapter devoted to that affection, although the disease itself is to be 
regarded as not amenable to radical cure. If a morbid condition of 
the naso-pharynx is present, this of course should also be subjected 
to proper medication. 

The first indication for local treatment in the larynx consists in 
thorough removal of the accumulated crusts and inspissated mucus 
without undue irritation of the parts. The use of a brush or pro- 
bang will usually accomplish all that is necessary. In mild cases 
the laryngeal atomizer answers an efficient purpose in softening the 
crusts, and thus enabling the patient to expel them by voluntary 
effort. The lotions to be used for this purpose may be the same as 
those already recommended. 

After the parts are cleansed, local applications can be made, by 
means of the sponge or cotton pledget passed directly down upon the 
part, of one of the following in the order of preference : 



LARYNGITIS SICCA. 



641 



Argenti nitras, 
Zinci sulphocarbolas, 
Zinci chloridum, 
Acidum tannicum, 
Acidum lacticum, 
Tr. iodi comp., . 



gr. x. to xx. to the oz. 
gr. xv. to the oz. 
gr. x. to xv. to the oz. 
gr. xx. to the oz. 
3 ss. to the oz. 
3 i.-iij. to the oz. 



The passing of a brush or probang through the glottis is not an 
especially difficult manipulation, and is ordinarily accomplished by 
a quick movement during the act of inspiration. The part to be 
medicated, as a rule, is simply that portion of the larynx which is 
below the glottis. 

During the intervals of treatment it is well to direct the patient 
to make use, three or four times daily, if the symptoms aro distress- 
ing, of an inhalation, by means of the steam atomizer or from an ordi- 
nary hand-ball atomizer, of one of the cleansing solutions already 
given. A solution of lactic acid, two or three drops to the ounce, 
used in an inhalator has been known to give good results. Creasote 
has been used internally with benefit, but usually internal medication 
is not indicated. 
41 



CHAPTER LXXX. 

ACUTE PHLEGMONOUS LAKYNGITIS, OK (EDEMATOUS 

LAKYNGITIS. 

(Edematous laryngitis is used to designate that form of laryngeal 
inflammation which is characterized by unusual swelling of the parts 
as the result of serous infiltration. In the earlier literature we find 
the term " oedema of the glottis" in frequent use. 

A great confusion in classification is found among the different 
writers ; but it seems to me that those affections of the larynx which 
are attended with cedematous swelling may be divided into " phleg- 
monous laryngitis" and "symptomatic oedema," or simply oedema of 
the larynx, the latter term being used to designate those cases of 
oedema which are passive and non-inflammatory, while the terms 
phlegmonous laryngitis and acute submucous laryngitis are used to 
describe acute inflammation of the mucosa of the larynx occurring 
idiopathically or as a complicating lesion of an acute, active, deeply 
seated inflammation of neighboring structures, resulting in much 
tumefaction from serous infiltration. 

Etiology. — The most active and practically the only cause which 
we can find for the affection is an exposure to cold. The local condi- 
tion is an acute cellulitis. This occurs in other regions in the body, 
often from apparently slight causes ; that it may occur in the same 
manner in the larynx, clinical experience teaches us. 

In many instances, a mild acute laryngeal catarrh seems to act as 
a predisposing cause of the attack, although it may develop when 
the air passages are in a state of absolute health. 

Excessive use of or straining the voice is regarded by some as an 
active cause of the disease. 

It is more common among males than females, and is usually 
met with in early adult life, the majority of cases occurring between 
twenty and thirty; although instances have been observed as early 
as nine weeks and as late as eighty years of age. 

That the disease is a comparatively rare one is shown by the in- 
vestigations of Hoffman and Lestier. 

The view that the disease is really in many instances true erysipelas 



ACUTE PHLEGMONOUS LARYNGITIS. 643 

of tlie larynx, is undoubtedly correct, as the presence of Fehleisen's 
coccus has been detected in cases of phlegmonous laryngitis. 

It may arise in the course of typhoid fever, of variola, of diph- 
theria, croup, typhus, or any of the exanthems. It is frequently 
traumatic in origin, either as the result of inhalation of acrid vapors 
or hot steam, and may also in rare instances develop indirectly as the 
result of swallowing corrosive poisons, or, again, it may occur in 
consequence of the impaction of a foreign body in the larynx, or in 
the passage of such an object into the oesophagus. 

Pathology. — The morbid changes which occur are inflammatory 
in character, and at the onset are identical with those which char- 
acterize any ordinary acute inflammatory process involving mucous 
tissues. Its progress, however, is marked by an unusual activity 
both of vascular turgescence and especially of serous transudation, 
under the influence of which the membrane becomes enormously 
swollen and tense, especially in those situations where it is most 
loosely attached to the parts beneath, and where, therefore, there is 
the least mechanical obstacle to the serous distention. These are the 
ary-epiglottic folds, the ventricular bands, and the posterior surface 
of the epiglottis. Involvement of the vocal cords is somewhat infre- 
quent, while extension to the subglottic portions of the larynx is a 
still rarer event. 

The swelling diffuses itself somewhat uniformly and symmetrically 
through both sides of the larynx. As the disease progresses, the 
transudation changes to a sero-purulent and finally terminates in a 
purulent infiltration with abscess formation. When the process goes 
on to the formation of an abscess, this is usually unilateral, but it 
has been known to be bilateral. 

Symptomatology. — The attack is ushered in by chilly sensations, 
or in rare instances by a well-marked chill followed by a mild febrile 
disturbance, the temperature ranging from 100° to 100.5° F. perhaps. 

The rapidity of the development of the local process in the larynx 
is shown by the fact that dyspnoea follows almost immediately upon 
the onset of the febrile movement. The voice becomes impaired or 
completely lost, and the breathing stridulous, both with inspiration 
and expiration. The further development of symptoms is of those 
which characterize increasing dyspnoea. Eespiration becomes 
labored, and the face florid and finally cyanotic. The extreme 
suffering of the patient is evidenced by his restless movements and 
anxious expression of countenance. These dyspnceic symptoms may 
develop in from twelve to twenty -four hours, or at the latest on the 
second or third day, when death ensues unless relief is afforded by 
tracheotomv or other remedial interference. 



644 



DISEASES OF THE LARYNX. 



The above description applies to a typical well-developed case 
of the disease which has resulted from a severe exposure. 

Diagnosis. — Our principal concern in meeting with a case of acute 
laryngeal dyspnoea is to determine whether we have to deal with an 
exudation, a phlegmon, a passive oedema, or the presence of a foreign 
body. The clinical history of the case will oftentimes aid us materi- 
ally in determining this question, although our main dependence must 
lie in the examination of the parts by the laryngeal mirror. The 
membrane presents a bright red color, is tense, somewhat glassy, and 
semi-opaque. In the severer cases the ventricular bands and the 
posterior face of the epiglottis will present three large rounded masses 

prominent in the field of vision and 
practically obscuring the parts be- 
low, and presenting a more or less 
contracted triangular opening be- 
tween them, through which respira- 
tion is carried on. There is evi- 
dence of active inflammation, but 
less tumefaction, in milder cases, 
while a unilateral phlegmon will be 
recognized by the same general ap- 
pearance. 

Prognosis. — The disease not 
only develops rapidly, but runs a 
somewhat brief course, usually ter- 
minating practically by the third or fourth day. In those severe 
cases in which the localized swelling so far interferes with respiration 
as to demand tracheotomy, the dyspnceic symptoms ensue usually in 
from twelve to thirty-six hours after the onset of the disease, the 
encroachment upon the breathing-space being due to a serous infil- 
tration. In the milder cases, which run a somewhat longer course, 
the serous transudation is rapidly followed by discharge of the pus. 
The inference we draw from this is, that if a case of phlegmonous 
laryngitis at the end of thirty-six hours has not developed grave 
laryngeal stenosis, we may fully anticipate that it will run its regular 
course and undergo suppuration without the necessity of trache- 
otomy. 

Suffocation constitutes the chief danger of the disease. 
Treatment. — The first indication for treatment is to secure such 
local depletion as is possible by free scarification of the inflamed 
membrane. This can be accomplished by means of Tobold's con- 
cealed lancet or any other laryngeal knife that may be available (see 
Fig. 134). Failing these, resort may be had to an ordinary curved 




Fig. 133.— Acute Phlegmonous Laryngitis. 



ACUTE PHLEGMONOUS LARYNGITIS. 



645 



bistoury, the blade being wrapped with thread up to within a quarter 
of an inch of its point. These scarifications should be made freely, 
not only along the face of the epiglottis, but on the swollen ventricular 
bands. The laryngeal mirror will assist or the finger may be passed 
in the fauces, provided the dyspnoea is not too great. These scarifi- 
cations should be repeated twice or 
three times a day, to relieve the tur- 
gescent blood-vessels, and to allow the 
infiltrated serum to escape. 

Steam inhalations may possibly add 
to the comfort of the patient. Blisters 
are of no avail, although the applica- 
tion of leeches over the crico-thyroid 
membrane is to be recommended. Cold 
applications to the larynx, either in the 
form of ice bags or Leiter's coil, if effic- 
iently and persistently maintained, are 
attended with excellent results. Pel- 
lets of ice may also be taken. 

Internal medication is not especially 
indicated, other than the administra- 
tion of an active saline cathartic. 

Should these measures fail to arrest 
the dyspnoea, tracheotomy will have to be performed. 

The cavity of the larynx is so far distorted that it is not probable 
that intubation would be successful. McEwen carried a case of 
phlegmonous laryngitis successfully through its graver dyspnceic 
stage by the insertion of an ordinary urethral catheter. 

Of course, when the pus formation can be recognized and reached 
by the knife, the pus should be evacuated. Unless the physician 
possesses special skill in this direction, tracheotomy should be 
preferred. 




Laryngeal Knives. 



CHAPTER LXXXL 

(EDEMA OF THE LAKYNX. 

The term " oedema of the larynx" should, I think, be restricted to 
that morbid condition of the larnygeal cavity which is characterized 
by a somewhat extensive serous infiltration of the soft parts, and in 
which the oedema is the prominent and practically the only local 
lesion. We undoubtedly have a certain amount of oedema with a 
phlegmonous laryngitis, with perichondritis and other inflammatory 
affections. But the essential lesion in these disorders is inflamma- 
tion, and the use of the term " oedema" in connection with them is 
misleading. In syphilis, tuberculosis, and occasionally in malignant 
disease of the larynx, the oedematous infiltration is entirely a sec- 
ondary development. 

Etiology. — The cause of the disease is to be found in some local 
or general condition outside of the larynx, under the influence of 
which a localized anasarca occurs. Any condition which may cause 
a dropsical effusion in other portions of the body may give rise to 
the same in the larynx. The most common cause is to be found in 
some form of renal disease. 

Whether any local condition of the larynx exists which predis- 
poses or invites the serous effusion into the laryngeal tissues, can 
only be a subject for speculation. 

Quinke has described, under the name of "acute circumscribed 
oedema of the skin," a most curious affection, which is characterized 
by the sudden appearance, in different parts of the surface of the 
body, of circumscribed areas of oedema, which, persisting for a few 
days, subside, subsequently reappearing elsewhere. They are ac- 
companied with a moderate amount of gastro-intestinal disturbance. 
This writer observes that the larynx may be invaded in the same 
way, and instances have been reported under the name of " angio- 
neurotic oedema of the larynx." The view taken is that the disease 
is essentially a vaso-motor paresis, the result of a general neurotic 
condition. The hereditary character of the affection has been thor- 
oughly traced by Osier. Vogt and Tait have reported instances of 
oedema in the larynx in new-born children as the result of placental 
degeneration. 



(EDEMA OF THE LARYNX. 647 

Pathology. — The essential lesion of the disease consists in the 
escape of liquor sanguinis from the blood-vessels, which diffuses 
itself in the submucous tissues of the lining membrane of the larynx, 
giving rise to an extensive swelling and distention of the parts, es- 
pecially in those containing the largest amount of areolar tissue. As 
a rule, we meet with three distinct serous sacs, as it were, one on 
either side, formed by the distended ary -epiglottic folds, and one 
anteriorly, formed in the mucous membrane covering the epiglottis. 
The tumefaction of the ary -epiglottic folds extends downward to and 
involves the ventricular bands, the membrane covering the arytenoid 
cartilages and the commissure, while in front the oedema, starting 
on the posterior aspect of the epiglottis, mounts to the epiglottic 
crest, and passes over and is liable to extend as far as the glosso- 
epiglottic fossa?. In rare instances the oedema confines itself to the 
ventricular bands without invading the epiglottis. 

An extension of this form of oedema to the true cords or to the 
parts beneath is an exceedingly rare occurrence. 

Symptomatology. — The onset of the attack is sudden, and the first 
symptoms which the patient experiences are usually those attendant 
upon obstruction to respiration. The voice is not necessarily lost 
at the onset of the attack, although as the cedematous swelling in- 
vades the ventricular bands and arytenoid commissure, the vibrations 
of the cords are not only mechanically interfered with, but the move- 
ments of the glottis are markedly hampered. The prominent symp- 
tom of course is the dyspnoea ; this has mainly to do with inspiration. 
The attempt to draw air into the lungs, therefore, gives rise to a 
somewhat noisy, stridulous sound. Pain is not usually present, 
although there is a sense of fulness and distention in the throat, 
together with a certain amount of difficulty and perhaps pain in 
deglutition. 

The progress of the swelling is so rapid that extreme dyspnceic 
symptoms may set in, even a few hours after the first symptom, or at 
the latest probably in from twenty -four to thirty-six hours. After the 
stenosis is fully developed, we have the general resulting symptoms, 
such as cyanosis, restless movements, anxious expression of face, and 
other evidences of the suffering which ordinarily accompanies the 
distress for breath. 

Diagnosis.— The subjective symptoms of laryngeal stenosis are 
usually so well marked that, as a rule, our main consideration is to 
determine the special form of laryngeal disease which is the cause of 
the symptom. This can be ascertained either by digital exploration 
or laryngoscopic examination. If the epiglottis is swollen, the inser- 
tion of the index finger will easily recognize the large, rounded, semi- 



648 



DISEASES OF THE LARYNX. 



resisting mass beyond the base of the tongue. If the oedema is 
confined to the ary -epiglottic folds, digital exploration beyond the 
epiglottis would scarcely be tolerated, especially if any dyspnoea 
existed. In these cases a laryngoscopic examination should be made, 
as an ocular inspection of the parts alone will absolutely determine 
a differential diagnosis between pure oedema, the presence of a foreign 
body, perichondritis, or other possible causes of the obstruction. 

The laryngeal mirror in position would bring into view the mucous 
membrane lining the larynx, presenting the two or three large, round 
swollen masses (see Fig. 135), according as the epiglottis is involved 
or not, encroaching upon the lumen of the larynx, and presenting 
between them the small triangular opening in the centre, through 
which respiration is carried on. The membrane presents a tense, 

semi-glassy aspect, of a grayish 
color and semi-translucent ap- 
pearance, resembling somewhat 
the aspect of an ordinary mucous 
polyp. The cedematous character 
of the swelling should be easily 
recognized; practically there are 
no laryngeal lesions with which it 
need be confounded. Angioneu- 
rotic oedema is preceded by cu- 
taneous eczema. 

Prognosis. — An oedema of the 
larynx is simply the local manifes- 
tation of some grave organic dis- 
ease, and the cases are rare in 
which a favorable change causes an arrest in the swelling. In any in- 
dividual case, therefore, wherein a purely cedematous invasion of the 
larynx is recognized, we may anticipate that dangerous dyspnoea will 
ensue in a comparatively few hours, if it has not already occurred, 
unless our remedial measures are sufficiently prompt and efficient to 
arrest its further progress. 

Treatment.— Our first endeavor should be to ascertain, if possi- 
ble, the cause of the oedema, when prompt measures based on this 
should be instituted to prevent a further development of the disease. 
If the heart is at fault, and its action weak, one minim of either the 
fluid extract of digitalis or the tincture of strophanthus should be 
administered hypodermically. If there is kidney disease or cirrho- 
sis of the liver, free action of the bowels should be obtained by the 
administration of half a grain of elaterium, or, as perhaps securing a 
prompter action, a drop of croton oil may be given; at the same timo 




Fig. 135.— QHdema of the Larynx. 



(EDEMA OF THE LARYNX. 649 

free diaphoretic action should be secured by the hypodermic admin- 
istration of one-eighth of a grain of pilocarpine. This latter dose may 
be repeated after an interval of from three to four hours, although it 
must always be borne in mind, in using this remedy, that it is a 
cardiac depressant and is liable to induce oedema of the lungs ; hence 
its action should be watched somewhat closely, and, if the indications 
occur, alcoholic stimulants should be administered to counteract any 
observed unfavorable action on the heart. 

The patient should be kept in a warm room, and in an atmosphere 
thoroughly surcharged with moisture by means of boiling water over 
a spirit lamp. Our main reliance for immediate and prompt relief 
lies in freely puncturing the serous sac and letting out the water, as 
described in the chapter on phlegmonous laryngitis. These scarifi- 
cations should be made freely over the whole of the swollen surface, 
wherever tumefaction is found, and may have to be repeated at the 
end of two or three hours. 

As regards catheterization, intubation, and the performance of 
tracheotomy, the same rules apply as have been given in the discus- 
sion of the treatment of phlegmonous laryngitis. 

(Edema secondary to a tuberculous or syphilitic larynx very rarely 
attains proportions which demand local interference. In those in- 
stances, however, in which this complication occurs, the rules which 
govern our management of it are practically the same as those which 
govern an cedema dependent upon cardiac or kidney disease. 



CHAPTER LXXXIL 

CROUPOUS LARYNGITIS. 

We have already discussed the question as to the duality of croup 
and diphtheria, taking the ground that the two diseases are separate 
and distinct, and that we meet with a group of cases which are char- 
acterized by fibrinous exudation in the larynx, and in which none of 
the septic features of diphtheria are present. This affection we 
designate as croupous laryngitis. As compared with diphtheria, it 
is an exceedingly rare affection ; but that it does occur I am con- 
vinced, as the result of the careful study and observation of a number 
of instances of membranous laryngitis, in which the peculiar character 
of the membrane convinced me that they should not be included in 
the same category with a true diphtheria. 

Etiology. — Although at the present writing the specific germ 
which gives rise to a croupous laryngitis has not been isolated and 
subjected to culture, I am quite as firmly of the belief that the dis- 
ease is the direct result of the lodgement of a microbe in the fauces 
or larynx as that diphtheria occurs in this way. It is possible that 
this germ is closely related to, but not identical with that which 
causes diphtheria, the latter, however, being a microbe of infinitely 
greater activity. The lymphatic tissues in the fauces afford a con- 
venient lodgement for disease germs, and it is here that in the very 
large majority of cases the primary deposit occurs, either in the 
faucial or pharyngeal tonsil. Whether the primary lodgement may 
occur in the larynx, we have no means of determining. I have seen 
no case, however, in which I could not demonstrate the existence of 
an exudation in the fauces before any evidence of laryngeal involve- 
ment was apparent. 

I believe that a croupous deposit in the fauces, whether in the 
form of an acute follicular tonsillitis or of a croupous membrane on 
the tonsil, is to be regarded as presenting a certain amount of danger 
of causing a croupous laryngitis, even though this extension of the 
disease is one of rare occurrence. 

We must recognize as the teaching of clinical observation that 
the croup germ is one of comparatively little vitality. It lodges upon 



CROUPOUS LARYNGITIS. 651 

the faucial tonsil, propagates, and gives rise to an acute follicular 
tonsillitis. In doing this it has apparently exhausted its vitality in 
the vast majority of cases. In another case it lodges in the fauces 
and propagates with a greater activity than in the former, causing a 
diffuse membrane on the tonsils. In a certain proportion of cases, 
not so great as the former, the diseased process ceases without de- 
veloping laryngeal complications. A membranous deposit on the 
tonsils is to be regarded as indicating a much greater danger of a 
croupous laryngitis than the follicular disease. Susceptibility con- 
stitutes another exceedingly important feature of the disease. While 
a croupous exudation in both forms is very common in adult life, true 
croupous laryngitis is rarely, if ever, met with. 

The disease occurs sporadically and endemically, never probably 
epidemically. It is is not to be regarded as contagious in any greater 
degree than the milder forms of croupous exudation, such as acute 
follicular tonsillitis. 

An ordinary catarrhal cold involving the upper air passages, while 
standing in no direct relation to a croupous inflammation, must be 
regarded as a somewhat active predisposing cause of the graver dis- 
ease, the inflamed membranes affording a more favorable nidus for 
the lodgement and development of a disease germ. 

Pathology. — The onset of croupous inflammation is marked by 
the same phenomena which occur in connection with catarrhal inflam- 
mation. It differs from catarrhal inflammation, however, in the fact 
that the escaping serum contains a large amount of fibrin, which, 
passing through the superficial layer of the mucous membrane, coag- 
ulates upon its surface. The increase of the nutritive processes is 
characterized by the proliferation of large numbers of epithelial cells, 
which are imprisoned by the fibrin, thus forming a false membrane 
on the surface, which is composed of large numbers of fibrinous 
fibrillse, entangling in their interlacing meshes the proliferated epi- 
thelial cells. 

It would thus seem that the specific germ, penetrating the tissues, 
sets up primarily a catarrhal inflammation, and, furthermore, either 
itself enters the circulation or gives rise to ptomains which make 
their way into the blood, causing a condition of hyperinosis, which 
so far dominates the local morbid process as to give rise to a fibrin- 
ous inflammation or exudation. 

Symptomatology. — The disease is ushered in by a chill or notably 
chilly sensations. This is followed by an active febrile movement, 
which from the onset assumes the sthenic type. The temperature on 
the first day may range from 102 ° to 104° F. The skin is hot and 
flushed, and the pulse rapid and bounding. There is loss of appe- 



652 DISEASES OF THE LARYNX. 

tite, with pains in the bones, and the urine becomes scanty and high- 
colored. The child is restless and usually declines food, partially 
on account of the activity of the fever, and partially as a result of the 
painful symptoms which almost immediately develop in the throat. 
The parts feel dry, stiff, and sore, with perhaps a certain amount 
of external tenderness on pressure. The prominent local symptom, 
however, is a painful deglutition, each attempt being attended with 
sharp lancinating pains, which shoot toward the neck and ear. The 
febrile movement continues, and the range of temperature remains 
practically unchanged for from twenty -four to forty-eight hours. 
The local sj'mptoms in the throat may be prominent or masked, ac- 
cording to the extent of the deposit on the tonsils. During the first 
day, or possibly not until the second or third, evidences of laryngeal 
involvement will show themselves in the impairment of voice, which 
may become hoarse and metallic in character at first, although this is 
soon followed by more or less complete aphonia, the voice being re- 
duced to a hoarse whisper. Characteristic evidences of membranous 
deposit in the larynx soon follow, such as inspiratory and expiratory 
dyspnoea, the former being more pronounced and attended with sub- 
clavicular depression, cyanosis, pinched and anxious expression of 
the face, dilatation of the ala3 of the nose, etc. The involvement of 
the larynx is liable to be marked by a certain accession of febrile 
movement, with an increase of temperature of from one to two 
degrees. The further history of the case consists in the rapid in- 
crease of dyspnceic symptoms and the final death of the child, unless 
the disease is arrested or the exfoliation of the membrane is secured 
by the therapeutic efforts at relief. The laryngeal involvement sets 
in usually as early as the second day, rarely beyond the fourth, and 
the disease runs its course somewhat rapidly, terminating in death 
or resolution in from three to six days. 

Albumin is present in the urine in a certain number of cases. 
This, however, is not a feature of any special significance, as albumi- 
nuria is met with in acute follicular tonsillitis, as well as in most of 
the other acute infectious diseases. 

Diagnosis. — A point of special importance lies in the differential 
diagnosis between croupous and diphtheritic inflammation. In the 
graver disease we have a thick, yellow, efflorescent false membrane, 
closely adherent to the parts beneath, and which cannot be separated 
from them without the rupture of blood-vessels, and furthermore the 
exudation at the end of twenty -four hours shows marked evidences 
of necrosis. The croupous membrane, on the other hand, is a clean, 
vital membrane, bluish-white in color, thin, but slightly raised above 
the parts beneath, and constitutes an entirely superficial deposit. 



CROUPOUS LARYNGITIS. 653 

The special diagnostic point lies in the fact that it is easily detached 
from the parts beneath without the rupture of blood-vessels. 

Laryngeal examination is not often feasible in very young chil- 
dren ; but even if this were obtainable, as we have already seen, the 
fibrinous exudation in the larynx in diphtheria is practically a croup- 
ous membrane, and therefore one which differs in no great degree 
from the disease under discussion. Our diagnosis, therefore, will be 
based on the appearances observed in the fauces on direct insi>ection. 
I seriously question whether a case of laryngotracheal diphtheria, 
so called, ever occurs without a diphtheritic inflammation in the 
fauces. If such is not met with, I should be disposed to call the dis- 
ease croupous laryngitis, although undoubtedly many good observers 
call these cases diphtheria. Any given case, therefore, with a faucial 
exudation which at the end of twenty-four or thirty-six hours has not 
assumed a diphtheritic character, must be regarded as a croupous 
disease. 

In all cases, whether they resemble true diphtheria or not, a 
culture should be taken and submitted to bacteriological examination. 
In laryngeal cases, however, the failure to find the Klebs-Loeffler 
bacillus is not considered by some authorities as invariably a proof 
of the absence of diphtheria. 

Prognosis. — The tendency to death in croupous laryngitis is 
entirely due to the dyspnceic symptoms. The patients die of suffo- 
cation, and not from the activity of the blood poison or the promi- 
nence of the febrile symptoms. In a majority of instances of true 
croup we are driven sooner or later to our last resource, namely, to 
open the air passages, a measure which is successful in but a very 
small proportion of cases in which the trachea and bronchi have been 
invaded, whether the case be croupous or diphtheritic in its origin. 

Treatment. — Mercury exerts a somewhat specific influence upon 
fibrinous exudation. This drug, therefore, affords us better hope of 
controlling the exudation than any other. It should be administered 
preferably in the form of calomel or hydrargyrum cum creta in some- 
what full doses from the onset of the disease, bearing in mind the 
tolerance of children for this remedy. For a child five years of 
age two grains of either of the above preparations should be admin- 
istered, suspended in milk or some other suitable fluid, every two 
hours for the first twenty -four hours, or until the evacuations are 
rendered greenish in color and soft in consistency, after which it 
should be administered at less frequent intervals. 

Next in value and importance to the preparations of mercury in 
this disease is the tincture of iron. This should be given in glyce- 
rin in the proportion of one part to eight, of which to a child five 



654 DISEASES OF THE LARYNX. 

years of age a half-teaspoonful is to be administered every two hours. 
Given in this form, the iron exerts a directly controlling action upon 
such local exudation as may exist in the fauces. Its systemic effect 
is of even more importance than this, in that the drug seems to pos- 
sess certain specific properties in controlling that peculiar blood con- 
dition which we have heretofore spoken of as hyperinosis and which 
exists in so marked a degree in the disease under consideration. A 
better action, I think, of each drug is obtained by administering 
them alternately rather than in combination. 

The indications for treatment, so far as the local exudation in the 
fauces is concerned, consists in the application of the liquor ferri 
persulphatis, the membrane being saturated with this drug applied 
by means of a pledget of cotton wrapped on a slender probe, and the 
application repeated every two or four hours, according to the prog- 
ress of the case. 

When the membrane develops in the larynx, a region which is 
practically not freely open to access for nice manipulation in these 
cases, and which cannot be easily inspected in young patients, we 
probably possess no method which is capable of arresting the . prog- 
ress of a fibrinous exudation after it has commenced. We may hope, 
however, in a small proportion of cases to bring about such rapid 
evolution of the membrane that exfoliation may take place before the 
patient succumbs from asphyxia. Our main reliance for the accom- 
plishment of this lies undoubtedly in the inhalation of steam, and 
probably the best method of generating this is by slaking lime. 
The steam which arises during this process of hydrating the lime 
undoubtedly carries with it small particles of the chemical, which 
possibly may have some beneficial action upon the exudation. It is 
not necessary that these should be constantly used, but they may be 
repeated every four to six hours. During the intervals, however, 
and practically as long as the dyspnoeic symptoms persist, the child 
should be subjected to the action of steam constantly generated from 
a spirit lamp. In order to best secure this, it should be covered with 
a tent, which can easily be arranged by means of sheets and blankets. 
Whether any additional benefit is derived by adding to the boiling 
water lactic acid, acetic acid, creasote, oil of tar, camphor, benzoin, 
cubebs, carbolic acid, thymol, iodine, turpentine, and other drugs, 
is open to question. 

In former years, when all pseudo-membranous affections of the 
throat were designated as croup, emetics were very generally and 
extensively used in this disease; of late years and since the diph- 
theritic character of the large proportion of these cases has been 
recognized, emetics have fallen very largely into disuse, on the ground 



CROUPOUS LARYNGITIS. 655 

that the harm that they are liable to do in a disease of such purely 
asthenic character as diphtheria more than counterbalances any 
problematical good. They may occasionally prove of value in a case 
of croupous exudation in enabling a child during the act of vomiting 
to detach an already loosened false membrane in the larynx and 
trachea and to expel it. In order that the emetic shall perform this 
service, it is easy to see that detachment must already in part have 
been accomplished. In order to be of any value, emetics must be 
resorted to with great discrimination and nicety of judgment. In 
selecting an emetic, preference should be given to the yellow subsul- 
phate of mercury, or turpeth mineral. To a child five years of age, 
the dose should not be less than ten grains. 

Pilocarpine not only increases diaphoresis through the cutaneous 
system, but also stimulates the mucous secretions. It is thought by 
some to promote the separation of the false membrane, an observa- 
tion which seems to have been confirmed by a number of writers. 
The remedy is a somewhat powerful one, and should therefore be used 
with considerable caution. For a child five years of age, probably 
quite a safe dose would be a twentieth of a grain. This may be 
repeated at the end of from six to twelve hours, its effect being watched 
carefully. 

Notwithstanding our remedial efforts, in a majority of cases the 
fibrinous exudation continues to develop, and dyspnceic symptoms of 
an increasingly grave character ensue, when the resort to surgical 
interference becomes imperative. It is scarcely necessary to add, 
that an early operation gives us the best hope of saving the life of 
the patient, for the long continuation of laryngeal stenosis, especially 
in a young child, tends not only to depress the vitality and recupe- 
rative power, but also induces conditions in the mucous membrane 
of the larynx and bronchial tubes which, to an extent, invite the ex- 
tension of the fibrinous exudation. Considering that here we have 
to do with an exudation which is neither septic nor especially infec- 
tious in character, I think that there can be no question as to the 
advisability of the use of the O'Dwyer tube in preference to trache- 
otomy. This should be inserted immediately upon the development 
of any continuous dyspnceic symptoms. If from any cause the tube 
fails to relieve or is not easily retained in position, resort should be 
had to tracheotomy. 



CHAPTER LXXXIIL 

PEKICHONDKITIS OF THE LAKYNGEAL CAETILAGES. 

The morbid changes which take place in the laryngeal cartilages 
have their origin in the perichondrium, a primary chondritis, so far 
as I know, not being met with. 

From a clinical point of view, we meet with three varieties of 
morbid action in these tissues, namely, ossification, fibroid degenera- 
tion or chronic inflammation, and acute inflammation. 

Our present consideration has mainly to do with acute perichon- 
dritis, which possesses an especial interest on account of the sudden- 
ness of its invasion, the gravity of the symptoms which attend its 
development, the great deformity to which the laryngeal cavity is 
subjected thereby, and especially the obscurity and difficulty of diag- 
nosis which often confront the surgeon at a time when a prompt and 
definite diagnosis is a matter of no little importance. 

Etiology. — A large proportion of cases occurs idiopathically, as 
the result of an exposure to cold, while among other exciting causes 
may be included typhoid fever, diphtheria, pneumonia, erysipelas, 
syphilis, and traumatism. We include syphilis among the exciting 
causes of the disease, for the reason that, when it arises from a 
specific lesion, it runs practically the same course as it does in other 
cases, although, of course, the indications for treatment are some- 
what different. 

Of the 33 cases which I have collated, including 2 occurring in 
my own practice, 9 were idiopathic, 9 were due to the syphilitic 
taint, 11 followed an attack of typhoid fever, 1 resulted from diph- 
theria, 1 was traumatic, and 2 were due probably to a lordosis of the 
cervical vertebrae pressing upon the cricoid cartilage. Excessive use 
of the voice has been suggested as a cause of the disease, and so has 
pressure of the cricoid cartilage upon the cervical vertebrae, and even 
the frequent introduction of the oesophageal sound. 

Men are more frequently attacked by this disease than women. 

Pathology. — The changes which take place in the tissue consist 
of an increase of the vascularity and cell production and the other 
changes, which characterize an ordinary attack of acute inflammation. 



PERICHONDRITIS OF THE LARYNGEAL CARTILAGES. 657 

The further changes which take place may consist either in the for- 
mation of pus, which, burrowing beneath the perichondrium, sepa- 
rates it from the cartilages beneath, resulting in necrosis of the 
latter, or, in rare instances, the new cells may become organized, re- 
sulting in the development of a true hypertrophic process. This 
latter form of the disease is that which constitutes more properly a 
chronic perichondritis. 

In most instances the disease primarily attacks and confines itself 
to a single cartilage, although occasionally all the cartilages of the 
larynx may be involved. When the arytenoid is attacked, it not 
infrequently extends to the cricoid. Of the 33 cases collated by the 
author, 23 involved the cricoid, 3 the thyroid, 4 the arytenoid, 1 the 
cricoid and thyroid, and in 2 cases all the cartilages of the larynx 
were involved. Schrotter places the order of frequency as follows : 
first, the arytenoids, then the epiglottis, then the cricoid, and last 
the thyroid. This is quite true if we include cases which are secon- 
dary to tubercular disease. 

Symptomatology. — The onset of the attack is characterized by a 
feeling of general malaise, with chilly sensations, and in rare in- 
stances hj a well-marked chill, followed by pains in the bones, head- 
ache, and loss of appetite, the thermometer indicating a temperature 
of from 100° to 101 F. Impairment of function, which is more or 
less prominent according to the special cartilage involved, soon de- 
velops. There is a sense of fulness or distention in the parts, 
together with tenderness on pressure, and in rare instances absolute 
pain, especially if the disease is of syphilitic origin. 

The Cricoid. — If the cricoid cartilage becomes the seat of the dis- 
ease, the perichondrium lining the inner surface of the cartilage is 
always involved, giving rise to extensive tumefaction and marked 
encroachment upon the breathing-space, in consequence of which 
dyspnoea becomes the most prominent symptom, setting in quite 
early in the attack, and interfering almost equally with inspiration 
and expiration. If the posterior face of the cartilage is involved 
dysphagia necessarily arises, on account of the pressure of the bolus 
of food on the inflamed tissue. Coincident with the occurrence of 
dysphagia, the voice becomes lost, or reduced to a hoarse whisper. 
This is in part due to the inflammatory action extending to the 
mucous membrane lining the lower portion of the larynx, but in the 
main is undoubtedly the result of an infiltration of the muscular tis- 
sue, thereby impairing the phonatory movements of the cords. This 
infiltration attacks the crico-arytenoid lateralis muscles more actively 
than the posticus, although in most instances probably both are to a 
certain extent involved. 
42 



658 • DISEASES OF THE LARYNX. ' 

Cough may be present, owing to the accumulation of mucus in 
the larynx, although this is rarely a troublesome symptom. 

The acute symptoms may persist for a few days, when undoubt- 
edly spontaneous resolution may occur, although I have met with no 
such case, and know of none such reported in literature. The usual 
course is either toward suppuration or hypertrophic changes. In 
either case the symptoms persist without much change. 

The ultimate result of the morbid process is necessarily the necro- 
sis of the cartilage and the formation of a sequestrum, which, being 
retained, becomes the source of pus formation, which discharges 
through fistulous openings either into the larynx or externally. This 
may be maintained for months or even years, until the sequestrum is 
finally thrown off or removed. 

The Arytenoid. — If the arytenoid cartilage is the seat of the dis- 
ease, it gives rise to a unilateral tumor, which encroaches upon both 
the air and food tracts, causing some dysphagia and a certain amount 
of dyspnoea. 

In this form of the disease, the crico-arytenoid joint becomes the 
seat of an effusion, which results practically in an ankylosis, abolish- 
ing the movement of the cord on that side, causing the voice to 
become hoarse and notably lowered in tone. After the cartilage be- 
comes necrosed, and a fistulous opening is established, the final ex- 
foliation occurs in a much shorter period of time than in cricoid 
disease. 

The Thyroid. — Perichondritis of this cartilage may involve the 
inner or outer face of the cartilage and one or both wings ; in the 
large majority of instances, however, the attack involves the inner 
face, and is usually unilateral. The symptoms to which it gives rise 
are mainly impairment of voice and interference with respiration. 
The vocal impairment is due to the coincident involvement of the 
mucous membrane lining the larynx, in the inflammatory action and 
also the swelling of the perichondrium which projects into the cavity 
in the neighborhood of the ventricular band, thus interfering with the 
phonatory movements of the cord of the side involved. This, of 
course, only occurs when the inner face of the cartilage is invaded. 
If the disease is unilateral, the voice becomes hoarse and lowered in 
tone. If both sides are involved, the voice is reduced to a hoarse 
whisper. Where the inner face of the cartilage is involved, the area 
of inflamed tissue becomes somewhat extensive; the tumefaction, 
therefore, encroaches to a notable extent on the normal breathing- 
space, giving rise to dyspnoea, which in unilateral cases is a source of 
great distress to the patient, while in cases in which both wings of 
the cartilage are involved this becomes an exceedingly grave and 



PERICHONDRITIS OF THE LARYNGEAL CARTILAGES. 659 

■urgent symptom. When the disease attacks the outer surface, it 
results in notable external deformity, usually appreciated by inspec- 
tion and palpation, while at the same time there is no little tender- 
ness on pressure, and perhaps localized pain. 

The involvement of both wings and both faces of the thyroid car- 
tilage practically occurs only in those instances in which all the car- 
tilages of the larynx are invaded, giving rise to a form of the disease 
which is attended with extensive destruction of tissue, and, as a rule, 
is followed by the ultimate death of the patient. 

Ordinarily, however, an attack of thyroid perichondritis consists 
in the unilateral development of a localized inflammatory process in 
the perichondrum of one face of the cartilage, usually the inner. This 
process goes on to suppuration and the establishment of a fistulous 
opening, which discharges pus, either into the laryngeal cavity or 
anteriorly through the cutaneous tissues. This usually occurs near 
the median line iu either case. After suppuration takes place, the 
tumefaction subsides to a certain extent, and this is followed perhaps 
by a slight amelioration of symptoms, although not marked. 

The thyroid cartilage is much more abundantly supplied with 
blood-vessels than either the cricoid or the arytenoid; hence, a thyroid 
perichondritis is not liable to result in such extensive cartilaginous 
necrosis as occurs in the other cartilages. We are more apt to have a 
superficial necrosis, in which the affected portion disintegrates and is 
discharged; hence, after a period of a few months or perhaps a year, 
the suppurative process gradually diminishes, and the parts heal with- 
out any serious loss of tissue or permanent impairment of phonation. 

The Epiglottis. — This organ, being a fibro-cartilage, never becomes 
the seat of a process similar to that already described. Perichon- 
dritis of this cartilage does not result in an abscess with necrosis, but 
rather in an ulcerative action ; moreover, this is rarely if ever idio- 
pathic, but is only secondary to tuberculosis, syphilis, carcinoma, 
and other destructive diseases. 

Diagnosis. — The suddenness of the onset of the attack, together 
with the general febrile disturbance which accompanies it, indicates 
that we have to deal with an acute inflammatory disease. When we 
consider, therefore, that the only acute inflammatory affections giv- 
ing rise to dyspnceic symptoms which are accompanied by febrile 
disturbance are perichondritis, croupous exudation, and acute sub- 
mucous laryngitis, it would seem that the diagnosis in these cases 
should not as a rule be obscure ; and yet, as a matter of clinical ex- 
perience, the diagnosis is, in the large majority of instances, involved 
in no little uncertainty, even after the case has been studied and 
observed for some days. 



660 



DISEASES OF THE LARYNX. 



The onset of a croupous laryngitis is generally characterized by 
more marked chilly sensations, while the febrile disturbance is far 
more active, the temperature usually running from 102°. 5 to 104° F. 
Moreover, if a croupous exudation is not discovered in the fauces, 
the laryngoscopic mirror should serve to reveal it. A submucous 
laryngitis gives rise to a notable tumefaction of an inflammatory 
character, involving the mucous membrane symmetrically on both 
sides of the larynx ; whereas a perichondritis develops a tumefaction 
presenting all the aspects of acute inflammation, which extends more 
or less to the mucous membrane of the surrounding parts, and yet it 
is confined, as a rule, to one side of the larynx and is usually irregu- 
lar in outline and distinctly asymmetrical. The obscurity in diag- 
nosis lies in part, perhaps, in the fact that one is called to these 

cases usually in an emergency, 
and when the examination is 
made an uncertainty remains as 
to whether some obscure growth 
or malignant disease may not 
have existed without giving rise 
to symptoms for some time be- 
fore the development of the acute 
attack. 

Our diagnosis, therefore, must 
be based on the exclusion of other 
acute affections and the character 
of the febrile disturbance, to- 
gether with ocular inspection by 
the laryngeal mirror. If the 
cricoid is involved there will be 
found a distinct tumefaction, irregular in outline, nodular in char- 
acter, projecting into the subglottic portion of the larynx and en- 
croaching upon the breathing-space, as seen in Fig. 136. The whole 
aspect of the case indicates an acute inflammation which involves 
the mucous membrane covering the tumor and extends to the 
parts above the glottis. While the tumor is practically below 
the cords, it gives the appearance of projecting somewhat into the 
supraglottic larynx, crowding up the arytenoid and vocal cord in such 
a way that the latter is brought into apposition with the ventricular 
band, thus more or less completely obliterating the ventricle. The 
movements of the larynx on the side affected are also notably ham- 
pered or practically abolished. 

One's first impression, on examining a case of this kind, is of a 
very extensive distortion of the laryngeal cavity; a careful study, 




Fig. 136. 



-Laryngoscopic Image in Perichondritis 
of the Cricoid Cartilage. 



PERICHONDRITIS OF THE LARYNGEAL CARTILAGES. 661 

however, of the regional anatomy by means of the laryngeal mirror 
should aid one materially to outline the distinct tumefaction, having 
its origin on the posterior segment of the cricoid, which is the part 
primarily involved in the large majority of cases. Extensive tume- 
faction is also found when one of the arytenoid cartilages is the seat 
of attack. Tuberculosis, the only condition liable to be confounded 
with this disease, is usually bilateral and exhibits minute, scattered, 
whitish-gray points on a grayish-pink membrane, while idiopathic 
perichondritis is purely inflammatory. 

If the thyroid cartilage is involved externally, the condition should 
be recognized by palpation and inspection, together with the careful 
analysis of general and local symptoms. When the inner face is in- 
volved, it gives rise to a distinct circumscribed tumefaction, project- 
ing directly into the laryngeal cavity, near the ventricular band, en- 
croaching somewhat on the breathing-space, and practically hiding 
the true cord. The local inflammatory process, as a rule, should serve 
to eliminate all neoplasms. 

Prognosis. — These cases run a somewhat protracted course, and 
yet they involve no special tendencies toward a fatal termination, 
other than as the result of laryngeal stenosis, which, of course, can 
be obviated by the prompt introduction of a tracheal tube. In those 
rare cases, however, in w T hich all the cartilages of the larynx are in- 
volved, death almost invariably results in the course of a few months. 
These cases of general invasion of the laryngeal cartilages are usually 
secondary to tuberculosis, carcinoma, or some other systemic disease, 
and hence, while the cartilaginous affection is a contributing cause, 
it is not always to be regarded as the active cause of the fatal issue. 

While the disease is not fatal, the ultimate result as to the voice 
and respiration becomes an interesting question in prognosis. The 
great danger of permanent respiratory obstruction is shown by the 
fact that of seventy cases compiled by Liming which survived trache- 
otomy, in sixty the permanent wearing of the tracheal tube became 
necessary. It should be remembered, however, that these were all 
cases which followed typhoid fever, persistent laryngeal stricture 
being particularly characteristic of that form of the disease which 
follows typhoid. 

Cases of thyroid perichondritis run a somewhat more rapid course 
than cricoid. The sequestrum which forms is liable to disintegrate, 
and be expelled through the natural passages, or a large sequestrum 
may form which demands operative interference. One of the remote 
dangers which this form of disease involves is the burrowing of pus 
beneath the deep tissues of the neck, into the anterior mediastinum, 
giving rise to suppurative inflammation in this space. 



662 DISEASES OF THE LARYNX. 

The arytenoid form of the disease results in a destruction of the 
cartilage, which is ordinarily expelled through the natural passages. 
The prominent result is usually a permanent ankylosis of the crico- 
arytenoid joint, which gives rise to a certain amount of vocal impair- 
ment. The principal danger of this form of disease is in its extension 
to the cricoid. 

Teeatment. — The treatment of the acute stage of the disease con- 
sists of active general and local antiphlogistic measures. Most im- 
portant of these, perhaps, are ice packs, or Leiter's coil, applied 
externally, together with the internal administration of pellets of 
ice, and local blood-letting by means of leeches or wet-cupping. 
Schrotter suggests the use of absorbents, such as mercurial ointment, 
iodoform, or iodol ointment, applied externally, or a solution of 
iodine and glycerin applied to the mucous membrane of the larynx. 
If the pain is great, Magendie's solution of morphine or a ten-per- 
cent solution of cocaine may be sprayed into the laryngeal cavity. 

In addition to the above, the bowels should be acted upon freely 
by the administration of a full dose of either blue mass or calomel, 
followed by a mild saline cathartic. 

Iodide of potassium should be administered in all cases, at the 
onset of the acute stage, and persisted in for a considerable period 
after the acute symptoms have subsided. 

Our later treatment of perichondrial inflammation consists in 
measures for the relief of the dyspnoea, the performance of trache- 
otomy when demanded, the management of the sequestrum, and, 
finally, the relief of the resulting stenosis. When it becomes neces- 
sary to open the air passages, laryngotomy should be done in prefer- 
ence to the low operation, in that this not only secures a certain 
amount of local blood-letting, but also leaves an opening through 
which access can be more readily obtained to the sequestrum in the 
case of cricoid perichondritis, and to purulent accumulations which 
may form in case the thyroid is the part involved. 

The case should be watched for the formation of a sequestrum, 
and measures taken to remove this as soon as it has become detached 
from the diseased perichondrium. The presence of the sequestrum 
undoubtedly stimulates connective-tissue formation; the longer it 
remains, therefore, the more extensive is the permanent deformity 
and stenosis which may be anticipated. Its early removal, therefore, 
becomes a matter of no little importance. 

A cricoid sequestrum may be removed through the tracheal open- 
ing, although a much safer procedure would be to enlarge the open- 
ing either vertically or laterally. A safer procedure still, perhaps, 
would be the reinsertion of the tube lower down, especially if the 



PERICHONDRITIS OF THE LARYNGEAL CARTILAGES. 663 

sequestrum is large. In a case reported by Hjort a large thyroid 
sequestrum was removed by thyrotomy. 

One of the most important measures for the preservation of the 
voice arid restoration of the breathing-space, I think, consists in the 
use of a Luer valve in connection with the tracheal tube. This is 
especially valuable when there is ankylosis of the crico-arytenoid 
joint, as considerable motion results from the forcible expiration 
which is accomplished by this device. 

The severing of the adhesions by the intralaryngeal knife and 
the dilatation of strictures by bougies are indications which may be 
carried out in individual cases. At best, a larnygeal stricture follow- 
ing a perichondritis is a condition which, as we have seen before, will 
often baffle our most skilful efforts. In one case reported a large 
portion of the larynx was extirpated and an artificial organ intro- 
duced, to the great comfort and relief of the patient. 



CHAPTER LXXXIV. 

LAEYNGEAL HEMOEKHAGE. 

Under this term we include cases of rupture of the blood-vessels 
of the larynx, with escape of blood into the submucous tissues, giving 
rise to hseraatomata, and also those in which the blood escapes 
through the surface of the mucous membrane, causing an haemoptysis. 

In former days all cases of haemopytysis were generally considered 
as indicative of pulmonary disease : the introduction of the laryngo- 
scope, however, enabled observers to recognize the laryngeal mucous 
membrane as a not infrequent source of hemorrhage. 

Etiology. — The frequent use of the term laryngitis hemorrhagica 
testifies to the fact that many writers believe that inflammation of the 
laryngeal mucous membrane forms an essential part of this affection. 
I think that the frequency of catarrhal laryngitis and rarity of 
hemorrhage of the larynx force us to the conclusion that a simple 
inflammatory process is not even an actively predisposing cause, and 
I consider " laryngeal hemorrhage" the better term, as defining the 
chief symptom of the disease without misleading us as to its origin. 
A careful study of the reported cases would seem to indicate that 
general conditions have quite as much influence in causing the attack 
as local lesions. Among the former are the hemorrhagic diathesis, 
cirrhosis of the liver and dilatation of the heart, the general debility 
of phthisis, and anaemia and malnutrition, vicarious menstruation 
and pregnancy. In many instances the attack comes on while the 
patient is in the enjoyment of perfect health, and it is often difficult 
to ascertain the real cause of the bleeding. Slight erosions in the 
larynx undoubtedly may occur, and be the site of ruptured blood- 
vessels and consequent hemorrhages. 

There are, however, but few localities in the upper air tract where 
erosions occur ; one of these is on the anterior face of the arytenoids, 
and in many instances the escape of blood has been traced to this 
point. 

Among the exciting causes of the attack may be noted the strain- 
ing of the voice in excessive use, especially when it has been weak- 
ened from any cause. Coughing, vomiting, straining, violent exercises 



LARYNGEAL HEMORRHAGE. 665 

and other acts which induce superficial plethora may also lead to a 
rupture of the laryngeal blood-vessels. That an acute laryngitis 
may in rare instances prove the exciting cause is illustrated in a case 
of Frankel' s, in which a hemorrhage seemed to be the direct result 
of the laryngeal inflammation. 

Pathology. — The escape of blood may be beneath the surface, 
constituting an extravasation, or the hemorrhage may be the result 
of a rupture of blood-vessels on the surface of the mucous mem- 
brane, giving rise to an haemoptysis. 

It usually occurs over a somewhat limited area or even at a single 
point. 

As we have already seen, it does not occur as the result of pre- 
disposing local causes, but is rather a diapedesis. 

If it is the result of an erosion of the mucous membrane, this is 
most likely to occur at the posterior insertion of the cords or on the 
anterior face of the arytenoid cartilage. 

According to Brown-Sequard, vasomotor disturbances of the 
mucous membrane may constitute a prominent predisposing patho- 
logical condition. 

Of course an opportunity for a careful investigation of the local 
condition is rarely afforded, in that the disease is probably never 
fatal. In one case, however, the patient died of natural causes, and 
minute investigation revealed vascular plethora, with an extravasa- 
tion of red blood corpuscles, thus clearly indicating diapedesis, which 
in this case was the result of cirrhosis of the liver and cardiac 
dilatation. 

Symptomatology. — If the case is one of simple extravasation or 
concealed hemorrhage, the symrjtonis consist of a sense of irritation 
in the larynx, with a possible disposition to cough, and alteration or 
loss of voice, with dyspnoea if the hematoma encroach upon the 
breathing-space. 

If the hemorrhage is an open one, the prominent symptom is 
haemoptysis. The blood comes up easily, and with slight effort at 
clearing the throat. It appears in small masses or streaks unmixed 
with saliva or mucus, which distinguishes it to a certain extent from 
pulmonary hemorrhage. When it is small in amount, it may lodge 
in the larynx and become clotted, in which case it is expelled, of 
course, in the form of dark-colored masses, and may continue for 
days without great variation in amount. 

A profuse hemorrhage from this region is rare and dyspnoea is 
seldom present. 

Diagnosis. — The important element of diagnosis is in determin- 
ing whether the source of the hemorrhage be from the lungs or the 



666 DISEASES OF THE LARYNX. 

upper air tract. Instances are not rare in which hemorrhage from 
the nose or naso-pharynx has given rise to an haemoptysis, the blood 
trickling down to the lower part of the pharynx or even into the 
larynx, and being subsequently expectorated. It becomes important, 
therefore, not only to make a laryngoscopic but a rhinoscopic ex- 
amination. Additional evidence is established, of course, by an 
examination of the lungs. Furthermore, in pulmonary hemorrhage, 
the blood is usually thoroughly mixed with mucus, while in a laryn- 
geal hemorrhage it is entirely distinct. If the blood is expectorated 
in inspissated or dry clots, this would always indicate the larynx or 
the parts above as its source. 

Coukse and Prognosis. — It involves, in itself, no very grave dan- 
ger to life. So far as I know, a fatal case of laryngeal hemorrhage 
has never been reported. 

Treatment. — If the case is one of concealed hemorrhage or hsema- 
toma, in which the tumor gives rise to notable symptoms, the mass 
should be opened. In those ca3es in which there is open hemor- 
rhage, the loss of blood is generally easily controlled by the local 
application of some simple and unirritating astringent, as follows 
and in the order of preference : 

Ferri et aluminis sulphas, .... gr. x. to the oz. 

Liquor ferri persulphas ttl x. to the oz. 

Acidum tannicum, gr. xx. to the oz. 

Argenti nitras, gr. v. to the oz. 

The application should be made preferably by means of the laryn- 
geal atomizer, and repeated once or twice daily, according to the 
severity of the attack. 

The use of the voice should be interdicted, and the patient directed 
to avoid all exercise as far as possible, while at the same time the 
food should be bland and unirritating. Warm or highly seasoned 
food and drinks should be forbidden. Pellets of ice held in the 
mouth, or ice applied externally to the neck, will be found especially 
serviceable. 

If the cough is troublesome, or the disposition to clear the throat, 
as the result of the laryngeal irritation, is not controllable, opiates 
should be administered with a certain amount of freedom. The use 
of tobacco or alcoholic stimulants is of course to be avoided. 

The internal administration of ergot, preparations of iron, sul- 
phuric acid, and those remedies which are supposed to have a sys- 
temic effect on hemorrhage may be made, if the amount of blood lost 
becomes in any degree serious, although, as a rule, the action of 
these remedies is not greatly to be depended upon. 



CHAPTER LXXXV. 

SYPHILIS OF THE LABYNX. 

The manifestations of this disease which are met with in the lar- 
ynx are: 1. The primary lesion; 2. Erythema; 3. The mucous 
patch; 4. The superficial ulcer; 5. The gummy tumor; 6. The deep 
ulcer; and 7, Cicatricial stenosis. 

The Primaky Lesion. 

So far as I know, but a single case of chancre of the larynx has 
been reported. It was followed soon bj- secondary manifestations, 
and seems to have presented no local features which differed essen- 
tially from an ordinary buccal chancre. 

Erythema of the Larynx. 

This manifestation of syphilis belongs to the secondary stage of 
the disease, and may develop as early as from four to six weeks after 
the primary lesion, although it occurs usually from the fourth to the 
sixth month. In rare instances its appearance may be delayed as 
late as two years or even later. 

From a pathological point of view, it is closely analogous to the 
cutaneous erythema, but it is not usually coincident with it, being 
more liable to develop after the cutaneous eruption has subsided. 
Like all syphilitic invasions of the larynx, it comes on somewhat in- 
sidiously and without marked subjective symptoms. If the vocal 
cords are involved, the voice is apt to be impaired or perhaps com- 
pletely lost. There is no localized pain or difficulty in deglutition ; 
in fact, both the subjective and objective symptoms are confined to 
a certain amount of impairment of function. 

Pathology. — The essential pathological tension which constitutes 
this manifestation of syphilis consists in a more or less dense infil- 
tration of the mucosa with embryonic or round cells, giving rise to a 
certain amount of swelling of the tissue, but the most marked change 



668 DISEASES OF THE LARYNX. 

which seems to result from this infiltration consists in an interfer- 
ence with the return circulation of blood, whereby there results a 
notable amount of venous turgescence. This infiltration may diffuse 
itself somewhat equably through the lining membrane of the larynx, 
giving rise to a uniform hyperemia, or in rare instances it may be 
distributed in circumscribed areas, thus occasioning an irregular 
vascular plethora, which gives to the membrane a somewhat mottled 
appearance. We can thus easily appreciate the characteristic differ- 
ence between an acute catarrhal inflammation of the laryngeal mem- 
brane and a syphilitic erythema, in that the first change which occurs 
in the inflammatory process consists of vasomotor paresis and the 
dilatation of blood-vessels. This is followed by cellular infiltration, 
the whole process being directed by certain influences exerted upon 
the vasomotor centres. In the syphilitic disease, on the contrary, 
the cellular infiltration comes first, and the vascular disturbances are 
secondary. The mucous membrane on the posterior surface of the 
epiglottis and of the ventricular bands and ary-epiglottic folds is 
usually involved, while in rare instances the vocal cords themselves 
are invaded. Fournier describes a protoplastic form of this disease 
in which the parts are much more swollen, the subjective symptoms 
more prominent, and localized prominences are occasionally observed. 

Diagnosis. — Our main reliance in diagnosis by ocular inspection 
lies in the peculiar dusky, sombre hue of the membrane, which is of 
a dark red, somewhat purplish tint, in contradistinction to the bright 
red, scarlet color which is characteristic of an acute idiopathic in- 
flammation. If the infiltration occurs in circumscribed areas, giving 
rise to that peculiar mottled appearance in the membrane already 
described, the evidence of a specific taint should be more clearly 
recognizable. In this form of the disease we still have the diffuse 
venous turgescence, with its dark red or purplish color, but this is 
intensified in circumscribed areas, varying in diameter from one to 
four lines. The hyperplastic form, with its characteristic color and 
its extensive and uniformly diffused swelling, should not easily be 
mistaken for any simple inflammatory process either of the mucous 
membrane or the perichondrium. Aside from the above considera- 
tions, we have no definite method of recognizing a syphilitic ery- 
thema other than by the clinical history of the case and the success 
of internal medication. 

Course and Prognosis.— The disease is one which disappears 
promptly and quickly under the influence of appropriate constitu- 
tional treatment, but if neglected may remain for weeks or months in 
the same stage, without, however, developing any graver manifesta- 
tion of syphilis. 



SYPHILIS OF THE LARYNX. 669 



The Mucous Patch. 

This lesion, like the former, belongs to the secondary stage of 
syphilis and is one of its exceedingly rare manifestations in the lar- 
ynx; indeed, the possibility of its occurrence has been questioned. 
That it may develop, however, in this region cannot be doubted, in 
view of the fact that instances of this sort have been recorded by 
many and competent observers. 

It may occur as early as six weeks after the primary invasion, or 
its appearance may be delayed for twelve months or even longer. 

Its most frequent site is on the upper surface of the vocal cords. 
It may also occur on the epiglottis, arytenoids, and ventricular bands. 

It gives rise to no pronounced symptoms other than those which 
may depend on its location. If the cords are affected, the voice is 
impaired; while if the patch appears near the free border of the epi- 
glottis, some slight pain in swallowing is experienced. It seems to 
set up no secondary inflammatory changes. 

The pathological lesion which constitutes a mucous patch has 
already been fully discussed elsewhere. It seems to manifest the 
same tendencies here as observed elsewhere, both in its persistence 
and tendency to recurrence. It may occur single or the lesion may 
be multiple. 

Diagnosis. — The main interest of this lesion of syphilis has to 
do with the question of diagnosis. The mucous patch in the larynx 
should be recognized by the same appearances which are character- 
istic of a similar manifestation of syphilis in other portions of the 
air tract. 

The Superficial Ulcer. 

This lesion of syphilis belongs also to the secondary stage of the 
disease, and occurs usually from two to seven years after the primary 
sore. It may develop from a mucous patch or be primarily the result 
of the breaking down of a superficial gummatous infiltration. 

The clinical features and pathology of this form of ulceration 
have already been so fully discussed in the previous chapters on 
syphilis of the nose and pharynx that it is not necessary to enter on 
the consideration of the disease here further than to state that a 
laryngeal ulcer of this variety presents the same general features and 
runs much the same course as in the parts above. 

A superficial ulcer is a somewhat rare form of laryngeal syphilis, 
and it is mainly important from a diagnostic point of view, and as 
indicative of the activity of the specific virus in the system. Its 




670 DISEASES OF THE LARYNX. 

prominent features under ocular inspection are the same as those of 
the nose and pharynx, already described. 

The possibility of syphilis developing in connection with a tuber- 
culous process should always be borne in mind, two instances of this 
kind having been reported. 

The Gummy Tumor, 

While the larynx may be invaded by any form of syphilis, from 
the primary lesion to the deep ulcer of the later stages, in the very 
large majority of instances in constitutional syphilis the part remains 
intact until from five to ten years, or even longer, after the primary 

sore, when it becomes the seat of a gum- 
matous deposit involving the deeper 
tissues of the mucous membrane and 
periosteum. 

Owing probably to the fact that the 
larynx is the seat of constant functional 
activity, a gummatous infiltration in the 
majority of instances breaks down so rap- 
idly that when the lesion is first observed 
the ulcerative process is fully established. 
fig. 137, -Gummy Tumor of Left Occasionally, however, from some obscure 

reason, the breaking down of the tissue is 
delayed, and the lesion presents itself either in the form of a single 
or multiple tumefaction or of a diffuse infiltration. 

Symptomatology. — A gummy tumor consists of an infiltration of 
the deep layers of the mucosa, which may extend also to the peri- 
chondrium, in which case the subjective symptom of pain becomes a 
rather prominent feature of the attack. When the soft parts are in- 
volved, such as the ary-epiglottic folds or ventricular bands, the 
localized pain is not liable to be so prominent, although the pressure 
to which the parts are subjected during the act of deglutition may 
give rise to a certain amount of uneasiness. This also occurs when 
the posterior walls of the larynx are invaded. The voice is impaired 
according as the movements or contour of the vocal cords is affected. 
If the tumor encroaches on the respiratory tract, dyspnoea necessarily 
ensues, or this symptom may arise in consequence of an oedema set 
up by the presence of the growth. 

Diagnosis. — A gummy tumor, whether single or multiple, presents 
in the form of a smooth, symmetrical, rounded tumefaction, which is 
ordinarily covered with healthy mucous membrane. It appears 
somewhat suddenly, and when it has attained its full development 
remains stationary, unless softening and ulceration occur. If the 



SYPHILIS OF THE LARYNX. 671 

membrane covering the tumor is inflamed, this is usually, probably, 
to be attributed to other and ordinary causes. The growth may vary 
from the size of a pinhead to that of a large cherry, and may occur 
in any portion of the larynx. The rapidity of the development, 
together with the subjective symptoms and the clinical history of the 
case, in connection with the smooth rounded outline of the tumor, 
should always give rise to a suspicion of syphilis ; and, whereas ocular 
inspection may not always enable us to establish a definite diagnosis, 
the effect of the administration of the iodide of potassium will in the 
course of a comparatively few' days determine whether we have a 
gummy tumor to deal with. 

Course and Prognosis. — The tendency of a gummy tumor is to 
break down into ulcerative action, though in certain cases this may 
be absent, or delayed for months and even years. 

The Deep Ulcer. 

This lesion of syphilis belongs to the tertiary stage of the disease, 
and rarely occurs under five years after the primary sore, and in a 
majority of cases probably after ten years have elapsed. 

It results from the breaking down of a gummatous deposit which 
has invaded the deep layers of the mucosa proper. 

In all forms of syphilitic disease in the larynx, the invasion is 
somewhat insidious, and the lesion may exist for a considerable pe- 
riod of time without giving rise to subjective symptoms proportionate 
to the gravity of the local morbid process. A certain amount of local 
pain, with perhaps tenderness on pressure, may attend the primary 
deposit, or impairment of voice or complete aphonia may be present. 
The occurrence of ulceration, however, is attended with a notable 
amount of secretion of muco-pus. This contains an admixture of 
shreds of black, necrotic tissue, and is usually in the early stages 
streaked with blood. Hemorrhage to any appreciable amount is an 
exceedingly rare event. 

The gummy tumor may so far encroach upon the air passages as 
to cause dyspnoea. After the ulcerative stage, however, interference 
with respiration does not usually occur, except in those rare instances 
in which oedema supervenes, and even when this develops it rarely 
attains such proportions as seriously to encroach upon the respira- 
tory passages. 

This form of ulcer occurs, in the order of frequency, upon the 
epiglottis, the vocal cords, the ventricular bands, and the arytenoid 
commissure. When it attacks the soft parts, it is usually unattended 
with any complications other than a limited amount of ©edematous or 



672 



DISEASES OF THE LARYNX. 



vascular tumefaction. When it occurs in the neighborhood of the 
cartilages, as near the arytenoids or the cricoids, the primary infil- 
tration is liable to extend to the perichondrium, giving rise to an 
attack of perichondritis. If this be sufficiently extensive, necrosis 
necessarily follows. Destruction of one or the other of the arytenoid 
cartilages in this manner is a frequent complication. The evidence 
of this complication lies in a certain amount of pain in deglutition, 
with swelling of the membrane covering the cartilage, together with 
impaired mobility of the cords and perhaps dyspnoea. 

If the perichondrium of the cricoid becomes infiltrated and a peri- 
chondritis is set up, there is localized pain, with tenderness on press- 
ure, increased impairment of voice, but, most prominent of all, of 

course, is the dyspnoea, which de- 
velops rapidly and in a majority of 
instances very soon renders trache- 
otomy necessary. 

The epiglottis is very frequently 
the seat of the tertiary ulcer, but, 
it being a fibro-cartilage, we have 
simply a process of caries, by 
which the organ is destroyed by 
a process of erosion (see Fig. 
138). Perichondritis is a compli- 
cation of the later stages of the 
tertiary ulcer. After the gumma- 
tous infiltration occurs, the dis- 
ease becomes to an extent local; 
the ulcer cicatrizes, a certain 
amount of contraction ensues, with impairment of the function, and 
a period of several months of immunity may elapse. Then another 
outbreak occurs ; new gummatous material is deposited, which under- 
goes ulcerative action. So long as the case is neglected, or the dis- 
ease not eradicated, the progress of the affection is characterized by 
these recurrent attacks. During the early years of a laryngeal inva- 
sion these relapses are characterized, as a rule, by simple attacks of 
ulceration. During the later years, when the organ has been perma- 
nently impaired, its lumen notably encroached upon by cicatricial 
contraction, its blood-vessels hampered, and its nutrition interfered 
with, deeper structures are invaded, and we have ulcerative processes 
complicated by perichondritis and necrosis. 

It is in this later stage of tertiary syphilis oftener than in the 
earlier years that we meet with localized oedema, and yet in my ex- 
perience oedema plays a comparatively unimportant part in laryngeal 




Fig. 138.— Destruction of Epiglottis from 
Syphilitic Ulceration. 



SYPHILIS OF THE LARYNX. 673 

syphilis, and instances are exceedingly rare in which this complica- 
tion has given rise to grave symptoms. 

The pathology of the gummy tumor, with the manner in which 
ulceration arises from an endarteritis obliterans, has already been 
sufficiently discussed in a former chapter. 

Diagnosis. — The recognition of the deep ulcer, with its sharp-cut 
edges, dark red areola, excavated surface, and the profuse purulent 
secretion admixed with necrotic tissue, should ordinarily present no 
great difficulties. In tuberculous disease we have no areola, marked 
pallor of the mucous membrane, a whitish-gray ulcerated surface, 
flush with the surrounding membrane, no depression, and a scanty 
secretion of ropy mucus. 

In lupus we have the irregular contour, highly injected membrane, 
but no ulceration, no secretion of pus, and no exfoliation of necrotic 
tissue. 

In sarcoma we have a distinct tumor, with perhaps an eroded sur- 
face, but no distinct ulcerated surface with pus secretion. 

In carcinoma we have a hard, nodular tumor, with a ragged ulcer- 
ation, the edges of which are not sharply cut; the ulcerated surface 
does not present the crater-like aspect of syphilis ; we have the ten- 
dency to hemorrhage, and no well-marked areola. Furthermore, in 
the ulcerative stage of carcinoma we ordinarily find the large, swollen 
cervical lymphatics, together with, in most instances, the peculiar 
cancerous cachexia. 

Prognosis. — The prognosis in the early stages of larnygeal syph- 
ilis is fairly good as regards an arrest of the disease, and yet I think 
in tertiary laryngeal syphilis it is well to be somewhat guarded in 
giving an opinion as to ultimate success of treatment, especially as 
regards the complete restoration of function. 

Cicatricial Stenosis. 

The stenosis of the larynx which occurs in the late stage of syph- 
ilis is the result of a previously existing ulcerative process. 

When the cicatrized tissue undergoes contraction, the normal con- 
tour of the larynx is to an extent destroyed, its lumen distorted, the 
breathing-space notably encroached upon, and the vocal function 
seriously impaired. 

Some observers have entertained the view that the lesion occurred 
as the sequence of a deep-seated infiltration setting up a sort of sub- 
mucous laryngitis, which in its late stages developed the laryngeal 
stenosis without ulceration. I have never seen any case of this 
disease in which the gross appearance of the parts did not warrant 
43 



674 DISEASES OF THE LARYNX. 

me in regarding the stenosis as due to a contracting cicatrix follow- 
ing a tertiary ulcer. 

The symptoms to which the condition gives rise are impairment 
of voice and interference with respiration. Cough, with increased 
secretion, if present, should be regarded as an evidence of disturb- 
ance of the air passages lower down. Localized pain or tenderness 
on pressure may occur with the fresh syphilitic outbreaks, and are 
to be regarded as more directly symptomatic of a new gummatous 
deposit. Difficult or painful deglutition may be either due to coin- 
cident infiltration of the pharynx or parts above, or it may arise 
from a fresh gummatous deposit in the posterior wall of the larynx. 
The voice may be either simply impaired or completely lost, the 
patient being compelled to articulate in a whisper ; yet in either case 
we have that coarse, harsh, raucous tone which to an experienced 
ear is characteristic of late laryngeal syphilis. Dyspnoea usually 
attends both inspiration and expiration, although it is usually more 
marked in the former, owing to the fact that during this act the softer 
tissues above the vocal cords are apt to roll in, in a valve-like way, 
as it were, upon the glottis, thus increasing the stenosis. The 
dyspnoea is increased on exertion, as is the case in all form of laryn- 
geal stenosis. In the earlier stages of the disease this symptom is 
not very prominent, but the narrowing of the larynx increases slowly 
but surely, as the result of the persistent contraction of the connec- 
tive tissue which forms the cicatrix. 

The clinical history of the case is liable to be marked by fresh 
outbreaks of gummatous infiltration followed by ulceration, under 
the influence of which the stenosis is still more markedly and perma- 
nently increased, although undoubtedly in many instances a notable 
laryngeal stricture may develop after a single attack. 

Diagnosis. — The existence of a typical tertiary ulcer should render 
the diagnosis a comparatively simple matter. When we have to do 
with a pure cicatricial contraction without ulceration, the ravages of 
the disease present certain characteristics which to an experienced 
eye are unmistakable. No destructive ulcer in the larynx gives rise 
to such peculiar distortion of the organ as the cicatrices which fol- 
low the deep ulcer of syphilis. 

Practically the only disease with which syphilis of the larynx 
should be confounded is lupus. Our main reliance in making a 
differential diagnosis will lie in the fact that lupus does not take on 
true ulcerative action, and is never marked by the large bundles of 
cicatricial tissue which are seen in the cicatrices of syphilitic disease. 
The clinical history will help clear up the diagnosis. 

It is by no means an easy matter, and perhaps not an important 



SYPHILIS OF THE LARYNX. 



675 



one, to locate definitely the point of the stricture, for the reason that 
the whole cavit} r of the larynx is so completely distorted by the dis- 
ease. The ventricular bands are thickened, and usually adherent to 
the vocal cords, while the opening into the ventricles is obliterated. 
Both the true and false cords are more or less adherent, especially 
anteriorly, while the epiglottis is drawn down upon the larynx in 
such a way as largely to prevent careful inspection of the parts 
below. If the epiglottis has been involved in the ulcerative action, 
it is liable to be more or less completely destroyed, when the 
entrance of the larynx above presents a more or less rounded and 
ragged-looking circle, below which we see, in a progressively narrow- 
ing space, the ventricular bands merged into the true cords, and 
covered here and there with cicatricial bands, separated by areas 
of puffy, purplish-colored mucous 
membrane. Adhesions between 
either the true or false cords gener- 
ally occur anteriorly, thus leaving 
a narrowed breathing-space in 
front of the posterior commissure 
(see Fig. 139). 

Even in the comparatively early 
stage of the disease the crico- 
arytenoid articulation is largely 
involved on one or both sides, re- 
sulting in a fixation at or near 
the median line, thus giving rise 
to a condition which materially 
increases the stenosis. The oc- 
currence of this fixation in the 
median line, as is the rule, is probably due to the fact that the ab- 
ductor muscles are weaker than the adductors. 

Course and Prognosis. — The clinical history of laryngeal syphilis, 
if we embrace its sequelae, is essentially a protracted one. If the 
disease is recognized at its onset and subjected to proper treatment, 
it may be arrested; but if the original gummatous infiltration has 
been extensive and ulceration has ensued, a certain amount of destruc- 
tion of tissue is the necessary result, and still further cicatrization 
and contraction must follow ; no local or general treatment can control 
this. 

The disease, of course, involves no dangers to life other than 
through the occurrence of suffocation, and this can always be avoided 
by an early resort to tracheotomy. 




Fig. 



139.— Cicatricial Stenosis of Larynx, the 
result of Syphilitic Ulceration. 



676 DISEASES OF THE LARYNX. 

TREATMENT OP LARYNGEAL SYPHILIS. 

The Primary Ulcer. — All authorities unite in the view that the 
primary sore presents no indications for treatment, a better proce- 
dure being to await the development of secondary manifestations. 

Erythema. — This lesion yields promptly to the administration of 
general remedies, after the manner already discussed. If the local 
process assumes an aggravated form, the same topical applications 
are indicated as those recommended in the treatment of a simple 
acute catarrhal laryngitis. 

The Mucous Patch. — The mucous patch in the larynx does not 
possess the same tendency to spread as when it occurs on the soft 
palate and pharynx, nor does it seem to be of the same persistent 
and recurrent type. 

Apparently it yields promptly to internal medication. If, how- 
ever, there should be any indication for local treatment, it is to be 
treated by cauterization in the same manner as a mucous patch 
elsewhere. 

The Superficial Ulcer. — This lesion is to be treated by cleansing 
lotions and local applications of iodoform or europhen; nitrate of 
silver in a sixty -grain solution has also been recommended. 

The Deep Ulcer and Gummy Tumor. — These lesions are to be 
treated after the manner already described in a previous chapter. 
Some recommend inhalations of corrosive sublimate, from 1 part in 
1,000 to 1 in 500, in all forms of syphilitic ulceration, administered 
by means of the ordinary atomizer or by the globe inhaler. 

Cicatricial Stenosis. — No internal medication is of any avail either 
in preventing the stenosis or in relieving it after it is developed. The 
iodides, moreover, are actually harmful, causing an iodic laryngitis, 
in which the dyspnceic symptoms are often dangerously aggravated. 
I am disposed to think that there is an especial danger in syphilitic 
laryngitis of this accident occurring, for whereas I have never seen 
an acute laryngitis excited by the administration of iodide of potas- 
sium when the larynx was in a healthy condition, I have in several 
instances observed it in laryngeal syphilis. 

I think we must consider this form of stenosis of the larynx as 
practically one which is to be treated in much the same manner as a 
stricture of any other tract, viz., continuous dilatation, divulsion, 
and section ; and practically these are the same measures which are 
to be resorted to in dealing with this form of laryngeal stenosis. 

The first to employ systematic dilatation in these cases was 
Schroetter, who devised a series of metallic bougies for use in cases 
in which a tracheotomy had already been done. 



SYPHILIS OF THE LARYNX. 677 

The dilatation by means of these bougies is necessarily a some- 
what slow process. In order to hasten the progress of the cure a 
number of instruments have been devised for the forcible dilatation 
of the stricture. As a rule, these are intended to be used mainly in 
connection with dilating bougies, as after the use of rapid dilatation 
the bougie is necessarily introduced in order to prevent the contrac- 
tion of tissue which would ensue unless this were done. In Fig. 140 
is shown Mackenzie's dilator, which consists of three blades bent at 
the proper laryngeal angle, and is operated by means of a screw at 
the proximal end. The instrument is introduced closed into the 
larynx, after which the blades are opened by turning a screw. The 
amount of distention accomplished is shown by an index and dial 
plate on the handle. 

Navratil's dilator, shown in Fig. 141, is constructed on some- 
what the same plan. 

A syphilitic stricture of the larynx is composed of dense, resist- 



03'NNVNJIl 




Fig. 140.— Mackenzie's Laryngeal Dilator. Open. 

ing bands of connective tissue, which do not yield easily to dilata- 
tion; and in many cases undoubtedly Mackenzie's instrument, and 
probably also Navratil's, might prove somewhat too delicate in con- 
struction. The three-bladed dilator described by Schroetter, con- 
structed on much the same principle as that of Mackenzie, only much 
heavier and stouter in every detail, is a valuable instrument in such 
cases. These instruments also are usually made use of after trache- 
otomy, although they do not involve the necessity of a tracheal 
opening. 

Stoerck has devised a three-bladed dilator, which is inserted 
through the tracheal opening, for the divulsion of these strictures 
from below. I regard the manipulation through the mouth as much 
more feasible. 

In those cases in which there is adhesion between either the true 
cords or the ventricular bands, or in which a web has formed across 
the glottis, some form of cutting instrument answers a better pur- 
pose, as a rule, than dilatation. 



678 



DISEASES OF THE LARYNX. 



The use of a naked knife in the larynx requires rather nice manip- 
ulative skill. It is probably safer in these cases to make use of a 
concealed knife, such as Schroetter's or Mackenzie's instruments, in 
which the cutting blade is made to emerge from a tube after the 
instrument is inserted into the laryngeal cavity. 

Whistler and Browne have devised instruments which consist of a 
combination of a cutting instrument with a dilator, and which possess 
the advantage of putting the tissues on the stretch before they are 
incised, thus rendering the cutting more thorough. 

The use of cutting instruments may not only be resorted to in the 




Fig. 141.— Navratil's Laryngeal Dilator. 



cases of a web in the larynx, or adhesion of the cords, but they are 
valuable in all forms of laryngeal stricture in facilitating the process 
of dilating. After incisions, however, the use of dilators is necessary 
to secure what has thus been gained, as otherwise the cut surface 
would adhere and no practical benefit be derived by the operation. 

It would seem that the simple measure of passing a catheter 
through the larynx, might be of service in the early stages of a 
syphilitic stenosis, and can be accomplished without a previous 
tracheotomy. In the later stages, however, the cicatricial bands are 
of such a dense and firmly resisting character that they yield only 
before metallic dilators or bougies. A metallic catheter might pos- 
sibly be used in this way, but the indications would certainly be 
much more directly carried out by intubation. 

Intubation certainly possesses the great advantage that it does 
not require tracheotomy, and that the treatment can be pursued 
while a sufficent patency of the air passages is maintained. O'Dwyer 
suggests that in those cases in which the stenosis is so great that a 
tube sufficiently large to admit of a proper amount of breathing-space 



SYPHILIS OF THE LARYNX. 679 

cannot be inserted, the patient be anaesthetized and the larynx for- 
eilby dilated until a proper-sized tube can be inserted. The greatest 
difficulty lies in the fact that the larynx is so far distorted by the dis- 
eased action that the ordinary tube is not easily inserted, and even 
after it is in situ is not easily retained. In those cases in which 
this measure is available, I think there can be little question that 
intubation offers r>robably the best method of dealing with a syph- 
ilitic stenosis of the larynx. 

Whatever measure is resorted to for overcoming the stricture, the 
contraction recurs, and these patients must be subjected to a period- 
ical course of treatment to recover such ground as has been lost while 
remedial measures have been in abevance. 



CHAPTER LXXXVL 

TUBEKCULOSIS OF THE LAKYNX. 

The development and course of tuberculous disease in trie pharynx 
bears so close a relation to that of a similar process in the laryngeal 
tissues, and so many points in connection with the disease have 
been fully discussed in the former chapter, that, to avoid repetition, 
the reader is referred to what was said there for fuller information. 
We have there taken the ground that the development of a tuberculous 
process acquires an added virulence, and occurs with greater rarity, 
according as it locates itself in the parts nearer to the outer world. 
This view was emphasized by the fact that tuberculous disease of the 
pharynx is in the very large majority of, if not in all, cases, a mani- 
festation of an acute miliary tuberculosis. As we approach nearer to 
the pulmonary tissues, the most favored site for tubercle develop- 
ment, and observe the process as it manifests itself in the larynx, we 
find it not only occurring more frequently than in the pharynx, but 
also assuming a less virulent character and taking on more of the 
features which characterize pulmonary phthisis, with the added symp- 
toms which are dependent upon the locality and functions of the 
larynx. 

Etiology. — Tuberculous disease manifests itself in the larynx 
under much the same general influences as those which govern its 
development in the pulmonary tissues. The direct cause of course 
is the lodgment or colonization of the tubercle bacillus, but there is 
also a " tuberculous diathesis," and by this we understand that peculiar 
systemic condition which, in a large majority of instances probably, 
if not all, is the result of heredity. Whether this condition consists 
in abnormally wide lymph channels, as suggested by Shakespeare, 
or some other systemic peculiarity, can only be a subject of specula- 
tion. The existence of this special diathesis we accept as a clinical 
fact. 

In the very large majority of instances, a tuberculous process in 
the larynx succeeds or accompanies a similar process in the lungs. 
It has long been a mooted question whether a tuberculous process may 
occur primarily in the larynx. That the larynx may be invaded 
before any other portion of the air tract has been clearly demon- 



TUBERCULOSIS OF THE LARYNX. 681 

strated in a case reported by Demme of a child aged four and a half 
years, dying of a tuberculous meningitis, in which the autopsy re- 
vealed tuberculous deposits in the larynx, while the pulmonary tissues 
were normal. The laryngoscope had already revealed the existence 
of tuberculous ulceration. 

A primary deposit of tubercle in the larynx can undoubtedly occur 
without involvement of the lung tisues. A recognized tuberculous 
process in the larynx is not, therefore, to be regarded in every case 
as sufficient evidence of tuberculous disease in the lungs. As a matter 
of clinical observation, however, in the very large majority of in- 
stances in which the laryngeal disease develops, this occurs in the 
course of a chronic pulmonary disease. Furthermore, if, at the time 
the laryngeal affection is recognized, the lungs show no physical evi- 
dences of diseased action, the morbid process in the upper air tract 
is the strongest possible evidence that the pulmonary tissues are 
seriously threatened, and the development of diseased action there 
will very soon make itself known. 

The disease occurs more frequently in adult life and between the 
ages of twenty and forty, and is also more common in males than in 
females. 

From an extensive collation of cases we conclude that in all cases 
of pulmonary tuberculosis the larynx is involved in nearly one-third, 
and yet from a clinical point of view, I am disposed to think that 
statistics given by Willigk are more nearly correct, and that we maj' 
anticipate that about thirteen per cent of cases of pulmonary tuber- 
culosis will develop an active disease of the larynx, viz., that form of 
tuberculosis which manifests itself by well-marked subjective symp- 
toms, and which is characterized by progressive waste of tissue. 
The general pathologj r of this disease has been sufficiently described 
in a former chapter. 

Its first manifestation in the larynx consists in a circumscribed 
deposit, usually in one side of the organ. The most frequent site for 
this primary invasion is in the membrane covering the arytenoid car- 
tilage or commissure. Next to this, in order of frequency, are the 
mucous membrane covering the arytenoid cartilage, ary-epiglottic 
fold, the true cord, and lastly the epiglottis. After the primary in- 
vasion, the other portions of the larynx become involved, as a rule 
by lateral extension, or, in rare instances, by new centres of tubercu- 
lous infiltration. After the ulceration has been established in one side 
of the larynx, it is probable that it may be transferred to the opposite 
side by a process of auto-inoculation. Ariza has reported two in- 
stances of long pedunculated growths attached to the posterior wall 
of the larynx, which he regarded as tuberculous in character, on ac- 



682 DISEASES OF THE LARYNX. 

count of a co-existing pulmonary tuberculosis, although their histo- 
logical structure was not definitely ascertained. The small wart-like 
excrescences which appear on the anterior face of the arytenoid 
commissure, and also occasionally in other portions of the larynx, in 
laryngeal phthisis, are conditions of common observation, and par- 
take of the characters of ordinary papillary growths. 

I cannot agree with Stoerk or Mandl in regarding these wart-like 
excrescences as possessing any diagnostic value in the early stages 
of tuberculosis, as they are not infrequently observed in a simple 
catarrhal inflammation of the organ. 

Symptomatology. — Impairment of voice is one of the earliest evi- 
dences of the tuberculous invasion of the larynx, due in the majority 
of cases to an interference with the approximation of the cords. 

In tuberculous disease, the impairment of voice manifests itself in 
its soft, weak, and somewhat aphonic character. This is especially 
true when the commissure of the arytenoids is so far infiltrated as 
to interfere with the approximation of the cords. 

As the infiltration or ulceration invades the cords, the voice be- 
comes more and more impaired. 

In rare instances it remains unaffected up to a very late stage. 

Symptoms referable to deglutition occur quite early in the course 
of the disease. If the arytenoids are the seat of the infiltration, there 
is a slight difficulty in swallowing, attended perhaps with a certain 
amount of uneasiness in the region during the act. This is due in 
part to the impingement of the epiglottis on the crest of the ary- 
tenoids, and in part to the pressure of the bolus of food. 

When ulceration occurs, the pain becomes more severe and in- 
creases with the extent of the swelling and ulceration of the parts, 
becoming a source of acute suffering only when the epiglottis is 
involved. 

Cough is almost invariably present, and, while usually due to the 
pulmonary disease, its severity and persistency are undoubtedly aggra- 
vated by the laryngeal affection. Especially is this true of the 
ulcerative stage, when the secretions accumulate in the larynx and 
prove an additional source of irritation on account of the difficulty 
which the patient experiences in dislodging and expelling them. 

The larynx is somewhat sensitive to pressure, and the patient 
experiences considerable pain on movement of the organ. This 
symptom, however, is not so prominent in the early stage of the dis- 
ease as it is after ulceration occurs. 

The sense of fulness and distention in the parts is experienced very 
early in the history of the disease, and is due to the tumefaction of 
the tissues, which gives a sense of soreness and stiffness to the parts. 



TUBERCULOSIS OF THE LARYNX. 683 

Free hemorrhage from the larynx is an exceedingly rare occur- 
rence; I have never met with a single instance in which such an 
accident occurred. 

If the infiltration extends to the perichondrium, a perichondritis 
is the result ; this accident does not prominently complicate the dis- 
ease, in that such a perichondritis presents none of the markedly 
painful symptoms which characterize an idiopathic attack of this 
affection. Necrosis of the cartilage necessarily follows such a com- 
plication. Instances of this involving the arytenoids have been 
reported. The necrosed cartilage may remain embedded in the tis- 
sues, or it may separate itself and be expectorated. The perichon- 
dritis, while not especially painful, may give rise to a notable amount 
of swelling and oedema of the mucous membrane covering it. 

A moderate amount of oedema in laryngeal phthisis is by no 
means uncommon, yet instances are exceedingly rare in which it 
develops to such an extent as to constitute a grave complication. 

When laryngeal dyspnoea becomes a prominent symptom, as hap- 
pens in rare instances, I am disposed to think that its source is not 
to be found in the ©edematous swelling so much as in a narrowing of 
the glottis from ankylosis of the crico-arytenoid articulation ; when 
this takes place the fixation is very liable to occur with the cords in 
or near the median line, giving rise to a condition similar to that of 
bilateral paralysis of the abductor muscles. 

The epiglottis being a fibro-cartilage, an extension of the tuber- 
culous infiltration to this part results in an ordinary ulcerative pro- 
cess, rather than in necrosis. 

Diagnosis. — Ordinarily, the subjective symptoms of laryngeal 
phthisis are so well marked, especially in those cases which super- 
vene upon pulmonary disease, that a diagnosis can be made with a 
considerable degree of certainty. A laryngoscopic examination alone 
will reveal to us the extent of tissue involved, the definite character 
of the lesion, and the stage of the disease. The assertion has been 
made by Yon Ziemssen that a tuberculous process in the larynx can- 
not be definitely recognized as such by ocular inspection in those 
cases in which the lungs are not also invaded. I think on the con- 
trary, that tuberculous disease presents appearances so typical and 
characteristic that we should be able to recognize it as such with 
comparatively little hesitancy. 

The primary effect of a tuberculous infiltration seems to be to 
cause, first, a certain amount of tumefaction of the part, and, sec- 
ondly, an interference with circulation. 

A laryngoscopic examination will show us in the mucous mem- 
brane of the larynx, usually in the arytenoid commissure, a swelling 



684 



DISEASES OF THE LARYNX. 



which in the arytenoid causes what is known as club-shaped ary- 
tenoids. One side is sometimes more involved than the other, al- 
though in my own experience these masses invariably presented an 
almost symmetrical outline. If the ventricular bands are involved, 
the condition is usually unilateral. If the epiglottis is involved, the 
infiltration very early invades the crescentic edge, giving rise to 
what has been described as the turban-shaped epiglottis (see Fig. 
142). Here, again, the tumefaction is usually symmetrical, although 
in the commencement of the invasion of this portion of the larynx I 
have seen a well-marked unilateral tumefaction. While, then, the 
circumscribed tumefaction, and in certain cases the unilateral distor- 
tion of the organ, should excite suspicion, especially in patients 





Fig. 142.— Tuberculosis of the Larynx, with 
Infiltration of the Epiglottis, producing the 
so-called "Turban-shaped " Epiglottis. 



Fig. 143.— Tuberculosis of the Larynx. Nu- 
merous miliary tubercles are seen lying 
just beneath the epithelial layer of the 
mucous membrane. 



suffering from pulmonary tuberculosis, the peculiar color which the 
disease presents in the first stage will go far toward eliminating any 
doubt as to the character of the lesion. 

At the onset of the disease, the membrane presents a dull grayish- 
yellow tinge, somewhat solid and semi-opaque in appearance. At 
the end of a few days, or at the latest, perhaps, at the end of a week 
or two, the membrane becomes studded with minute yellowish points, 
which mark the development of tuberculous nodules in the more super- 
ficial layers of the mucosa proper and immediately beneath the epi- 
thelial layer. They give rise to no superficial elevation, but can be 
seen somewhat hazily, as it were, through the semi-transparent epi- 
thelium (see Fig. 143). They are of a grayish-yellow tinge, and of a 
distinctly lighter color than the mucous membrane surrounding 
them. 



TUBERCULOSIS OF THE LARYNX. 



685 



The further development of the morbid process in the larynx con- 
sists in the breaking down of these small tuberculous nodules, and the 
establishment thus of minute points of ulceration, the borders of 
which, by a slow process of extension, widen until they meet similar 
ulcerated points in neighboring parts, and thus eventually there is 
established an ulcerated surface covering a more or less wide area. 

. After the stage of ulceration has set in, the morbid process 
assumes quite a different aspect. The change which now occurs 
consists practically in the destruction, by exfoliation, of the epithelial 
surface, and the uncovering of the tuberculous process in the mucosa, 
which now gives rise to a certain amount of superficial waste. In 
color the ulcer is still a grayish-yellow, although it is occasionally 
dotted here and there with minute 
elevations of a somewhat pinkish 
color. The surface is ragged and 
worm-eaten, as it were (see Fig. 
144). Frankel likens it to the sur- 
face of cut bacon, while La Boul- 
bene compares it to the track of 
earthworms in wet sand. To me, 
it has often suggested a dish of wet 
meal which birds have pecked at. 
The ulcerated tissue, as well as the 
infiltrated membrane surrounding 
it, is highly anaemic, and the color 
of the two portions is so closely 
alike that it is oftentimes not easy 

to detect where the unbroken mucous surface ends and the ulcera- 
tion begins. The edge of the ulcer is irregular in outline, and its 
surface flush with the surrounding tissues. In other words, while 
there is superficial waste, there is an equal amount of progressive 
tuberculous infiltration, which fully compensates for the superficial 
waste. The loss of tissue therefore, is not apparent, in that the 
general contour of the parts is practically maintained. Occasionally, 
the central portions of an ulcer may be slightly depressed, perhaps, 
but this is not the rule. 

The secretion from the surface of a tuberculous ulcer is a thick, 
tenacious, semi-opaque, ropy mucus, closely adherent and limited in 
amount. The secretion is grayish and semi-translucent, and con- 
tains few pus corpuscles. 

Although, as a rule, there is no notable loss of tissue, yet when 
the fibro-cartilage of the epiglottis becomes the seat of a tuberculous 
ulceration, there is a somewhat slow but progressive destruction of 




Fig. 144.— Extensive Tuberculous Ulceration 
of the Larynx. 



686 DISEASES OF THE LARYNX. 

this organ. The same is true, and to a less noticeable extent, with 
reference to the vocal cords. The arytenoid cartilages, in rare in- 
stances, becomes necrosed and exfoliated, not as the result of tuber- 
culous disease of the cartilage itself, but rather of the perichondrium. 
Even this, however, results in no very noticeable loss of tissue. The 
point which it is desired to emphasize in this connection is that the 
very extensive tuberculous infiltration of the mucous membrane, or 
the parts beneath, results in a thickening, which more than compen- 
sates for any superficial loss of tissue which is due to the ulcerative 
process on the surface. 

As before stated, tuberculous disease presents appearances which 
should not easily be mistaken for any other form of diseased action, 
and yet the discussion is scarcely complete without emphasizing the 
distinctive points of difference between this disease and syphilis, 
lupus, perichondritis, and malignant affections. 

In the superficial ulcer of syphilis, we have a distinctly yellow, 
purulent discharge, a slightly rounded excavation, surrounded by a 
reddened mucous membrane without swelling, in contradistinction 
to the tuberculous process in which the secretion is gray mucus with 
no excavation, and a mucous membrane surrounding it, which is 
absolutely bloodless and notably swollen. In the deep ulcer of 
syphilis, we have all the features of the superficial ulcer exaggerated, 
with the markedly injected areola surrounding it, and the profuse 
discharge not only of pus but of necrotic tissue. The possibility of 
the two processes occurring simultaneously in the same larynx is to 
be borne in mind. When this occurs, however, each disease seems 
to maintain its characteristic features. 

In lupus, we have a highly injected condition of the mucous 
membrane, with nodular swellings, exceedingly limited secretion, 
together with a possible appearance of ulceration, which, however, it 
is almost impossible to definitely outline and distinguish. 

Perichondritis may possibly be mistaken for a tuberculous infil- 
tration. In the latter process, however, the distinctly exsanguinated 
appearance presents a marked contrast to the highly injected and 
semi-oedematous aspect of inflammation of the perichondrium. 

In malignant disease, we have the unilateral tumor, with its 
irregular nodular outline, together with the highly injected mucous 
membrane covering it, and, when ulceration occurs, the more or less 
profuse secretion of an ill-smelling muco-pus, often charged with 
blood and necrotic tissue. Laryngeal stenosis, moreover, is charac- 
teristic of malignant disease, and rarely of tuberculosis. We have 
already asserted that the characteristic feature of vocal impairment 
in laryngeal phthisis is a weakness of the voice. The laryngoscopic 



TUBERCULOSIS OF THE LARYNX. 687 

examination will reveal, as the source of this weakness, either an 
ulceration involving the vocal bands themselves, or, what is a more 
efficient cause, an impairment in adduction, the result of an infiltra- 
tion of the arytenoid commissure. This impairment of motion of the 
cords may also arise from an involvement of the crico-arytenoid artic- 
ulation, giving rise to defective mobility, or even a complete anky- 
losis. This condition may occur either in one or both sides of the 
larynx. It is a curious clinical fact that when an ankylosis of this 
joint develops, the fixation is more liable to occur with the cord in 
the median line than in abduction. The examination of the larynx, 
therefore, will reveal an apparent paralysis of abduction, either one 
or both vocal cords lying in the median line, or possibly in the 
cadaveric position. The real lesion in these cases is to be regarded 
as an ankylosis of the crico-arytenoid articulation. A laryngeal 
paralysis in a tuberculous patient is to be regarded as of grave 
import. 

Prognosis. — When tuberculous laryngitis supervenes upon an 
attack of pulmonary disease, it is to be regarded as an exceedingly 
serious complication. When the disease develops primarily in the 
larynx, or simultaneously with a pulmonary invasion, it is to be re- 
garded as evidence that the tuberculous infection is characterized by 
unusual virulence and activity. 

The average duration of life after the onset of pulmonary phthisis 
is generally stated at about three years. 

From cases reported and from those in my own experience I con- 
clude that the average duration of life in pulmonary phthisis is three 
years; the average duration of life in pulmonary phthisis compli- 
cated by laryngeal disease is two years ; the average duration of life 
after the supervention of laryngeal complications is eighteen months. 

In individual cases, of course, the prognosis of laryngeal disease 
is markedly influenced by special circumstances, the most important 
of these being the progress of the pulmonary disease if such exists. 
If the lungs are in an advanced state of phthisis, the laryngeal dis- 
ease runs a more rapid course and leads to an earlier fatal issue ; if 
the pulmonary disease is in its earlier stages, and does not advance 
rapidly, the laryngeal disorder may run an exceedingly chronic 
course. If the epiglottis is involved, the subjective symptoms be- 
como of an exceedingly painful character, while at the same time the 
progress of the disease seems to be accelerated and ulceration sets 
in quite early. In a less degree the same is true when the mucous 
membrane covering the arytenoid cartilages and commissure is in- 
volved. If the ventricular bands, on the other hand, are attacked, we 
not infrequently find that the local lesion develops rather slowly. 



688 DISEASES OF THE LARYNX. 

From a practical point of view, of course, the more important 
consideration has to do with the prognosis of this affection, as re- 
gards treatment. Unquestionably, in the very large majority of 
cases, all measures of treatment fail to arrest the disease, and a fatal 
termination ensues sooner or later. We are justified, I think, in 
confining ourselves, in the discussion of prognosis, to the laryngeal 
manifestation, and may fairly claim a cure if the tuberculous process 
in the larynx is arrested, although the patient subsequently dies of 
the pulmonary disease. If our remedial efforts succeed in arresting 
the local lesion in the larynx, we are undoubtedly not only prolong- 
ing life but relieving our patient from a grave complication of the 
pulmonary disease, which is the source of an. amount of suffering 
and distress exceeded in but very few diseases which we encounter. 
In this view of the case, I am disposed to think that the prognosis is 
not so unfavorable as is claimed by most observers ; and whereas 
undoubtedly a majority of cases resist all remedial efforts, in a cer- 
tain proportion of instances, by a carefully carried out and judicious 
course of general and local measures of treatment, we may entertain 
a reasonable hope of arresting the morbid process, especially if treat- 
ment is begun in the first stage of the affection. 

In no ulcerative process, probably, are we able to detect in a less 
degree any reparatory effort on the part of nature than in tubercu- 
lous ulceration, and yet instances of spontaneous cicatrization have 
been reported. 

Treatment. — We have already, in the chapter on tuberculosis of 
the pharynx, discussed somewhat at length the mild plan of treat- 
ment, which in my own hands has been found most efficacious in the 
relief of tuberculous disease. This consists, first, in the thorough 
cleansing of the parts ; second, the use of a mild astringent ; third, 
the topical application of morphine, either in powder or solution; 
and fourth, in the stage of ulceration, the insufflation of iodoform. 

For the details of this method of treatment, the reader is referred 
to the former chapter. It is of the utmost importance that these 
applications should be carried out in such a manner as will in the 
least degree irritate the diseased part. For the la^nx, the solu- 
tion should be applied by means of the atomizer, and here the ordi- 
nary Sass spray tubes, worked with the compressed-air apparatus, 
are of special efficacy : the tongue being well protruded, and the beak 
of the spray tube being passed into the fauces until it projects over 
the epiglottis*, the sudden letting on of the pressure floods the cavity 
with a finely atomized fluid in such a way that the whole of the dis- 
eased surface is thoroughly bathed in the medicated solution before 
the parts can contract in such a manner as to shut off the cavity. In 



TUBERCULOSIS OF THE LARYNX. 689 

the absence of the compressed air, the hand-ball atomizer, deftly 
used, can be made to accomplish an excellent purpose. 

The iodoform is best applied by means of Ely's powder-blower 
with a properly curved laryngeal tip. By this instrument, the pow- 
der is distributed equably over the diseased surface in such a way as 
to cause the least irritation. 

Occasionally in the ulcerative stage a more permanent effect of 
the morphine will be obtained by combining it with the iodoform 
and a mild astringent, as in the following formula : 

I£ Morphinre, gr. x. 

Acidi tannici, 3 ij. 

Iodoformi, 3 vi. 

M. 

It is to be borne in mind always, in using morphine, that its con- 
stitutional effect is promptly felt when applied to the mucous mem- 
brane of the air tract; hence, care should be exercised in using 
certainly no more than the officinal dose. This plan of treatment is 
to be carried out two or three times weekly, or even daily, ac- 
cording to the relief given and the observed effect on the morbid 
process. 

In the stage of infiltration, I have rarely seen instances in which 
the subjective symptoms were not very notably relieved by this plan 
of treatment, and in most instances the local morbid process seemed 
to be notably retarded, as evidenced by the laryngoscopic appear- 
ances. 

With the development of an ulcerative process, of course, we have 
to deal with a much graver lesion ; and yet in this stage of the dis- 
ease I have seen a number of cases in which, by the daily resort to 
the above plan of treatment, cicatrization resulted; and although 
these patients ultimately died of pulmonary phthisis, the success of 
local measures in arresting the laryngeal complication was clearly 
illustrated. It should be stated, however, that in these successful 
cases the ulcerative process was confined to the ventricular bands, 
the vocal cords, or the commissure ; in no case have I seen more than 
temporary relief afforded in a case of laryngeal tuberculosis in which 
the epiglottis was involved. The iodoform, of course, is inert in the 
first stage, but in the ulcerative stage I am disposed to think that 
this drug is the important agent. Europhen, which is practically 
odorless, apparently possesses the same action as iodoform. 

In my experience I have failed to discover that cocaine possesses 
any valuable curative properties either in the stage of infiltration or 
of ulceration. It is of incalculable value, however, in those cases in 
44 



690 DISEASES OF THE LARYNX. 

which deglutition is painful, in that the temporary anaesthesia which 
is secured by its use enables the patient to take food and drink with 
ease and comfort, when otherwise this act would be attended with 
distressing pain. For this purpose I have been in the habit of sus- 
pending the cocaine in an oily menstruum, as follows : 

1$ Cocainae hydrochloratis, .... gr. xx. to xxx. 

Aquae, . 3 ss. 

Ft. sol. et adde 

01. petrolati, ad % i. 

M. 

This is to be inhaled by the patient as needed, from the Burgess 
atomizer. 

Of the inhalation of medicated solutions, by means of the steam 
atomizer, or dry inhalations of the gum resins, etc., I have already 
expressed my disapprobation in the chapter on " Tuberculosis of the 
Fauces." In the same place the excellent results obtained by 
Heryng and Krause, from the use of lactic acid, with or without scar- 
ification, have been discussed, as also the menthol treatment of 
Eosenberg and Schmidt's scarifications. In making applications of 
lactic acid to the larynx, the drug is carried down to the parts by 
means of a pledget of cotton on a probe, the manipulation being of 
course directed by the laryngeal mirror in situ. In view of the excel- 
lent results which have followed the lactic-acid treatment, I do not 
think we have done our full duty in any given case without fully test- 
ing its efficacy. In connection with it, however, the mild course 
of treatment before outlined should be carried out at the same time, 
since there is nothing in the one plan which in the least degree con- 
flicts with the other. 

In many cases, as the result of the extensive infiltration, or on 
account of a complicating oedema, the stenosis becomes so great as 
to demand tracheotomy. The propriety of this operation to relieve 
dyspnoea is of course beyond question. The temporary relief to the 
local symptoms, which in many cases seems to have followed open- 
ing the windpipe, has suggested the question whether tracheotomy 
might not be performed as a direct remedial measure in those cases 
in which no stenosis exists. 

From the results reported I conclude that, while the operation is 
not one to be generally recommended, we are not justified in con- 
demning it in all cases, for in those instances in which the localized 
pain becomes extreme in character, and the difficulty and distress in 
swallowing become so great as seriously to interfere with the taking 
of food, if the patient's general condition is such as to warrant the 



TUBERCULOSIS OF THE LARYNX. 691 

operation, I think we may fully anticipate that the absolute rest 
which tracheotomy affords to the laryngeal movements will serve to 
markedly alleviate the local pain and enable the patient to take food 
with much more comfort and ease. 

Schroetter very properly suggests that if the air passages are 
opened, the lower operation should be performed. If the trachea is 
opened to relieve dyspnoea, the operation should be done promptly, 
and without waiting until the stenosis becomes extreme. 

E. Frankel, in reporting his case of primary tuberculosis of the 
larynx, suggests the question of the advisability of an extirpation of 
the organ. In the absence of a certainty that the laryngeal invasion 
is primary I do not think the suggestion could be seriously enter- 
tained. 

Koch's lymph as a cure for the tuberculous process has not given 
the results hoped for it at the time of its introduction. Neither have 
the cantharidate of potassium, the chloride of gold and sodium, and 
the iodide of manganese, nor the rectal injection of sulphuretted hy- 
drogen been proved to possess any great efficacy. 

The indications for general treatment in a case of laryngeal dis- 
ease are practically the same as for pulmonary phthisis, and need not 
be entered upon here. Of course no one will undertake the manage- 
ment of a case of laryngeal phthisis without availing himself of the 
beneficial effects which can be obtained from cod-liver oil, iron, gen- 
eral tonics, creasote, opiates, and other remedies whose action is to 
control the various distressing symptoms of the disease. Especial 
emphasis should be given, I think, to the great value of creasote in 
these cases. I have seen the best results from doses which com- 
mence with one grain and increase to two or three grains, given three 
times daily. The same may be said of the enforcement of certain 
hygienic rules, such as the use of the bath, the regulation of the 
clothing, the proper ventilation of the living and sleeping apartments, 
etc., and a change of climate when possible. 

One of the greatest difficulties with which we have to contend in 
these cases is the administration of a proper amount of food, on ac- 
count of the pain with which deglutition is frequently attended. 
The great value of cocaine in producing temporary anaesthesia has al- 
ready been referred to. An ingenious suggestion has been made by 
Wolfenden, who reports that one of his patients, in whom deglutition 
was unusually painful, found that he could take fluids with consider- 
able ease by stretching himself prone upon his stomach, with the 
head lower than the feet, and sucking them through a tube. I have 
seen this method tried with great success. Of course, when neces- 
sary, the oesophageal tube can also be resorted to. Delavan has de- 



692 DISEASES OF THE LARYNX. 

vised a special apparatus for alimentation in this disease, which 
consists of a flexible catheter attached to a pumping apparatus, by 
which the food is forced into the stomach. The end is equally well 
accomplished by the ordinary nasal douche or fountain syringe, with 
a catheter attached. 



CHAPTER LXXXVIL 
LUPUS OF THE LABYNX. 

The development and clinical history of lupus in the upper air 
tract has already been so fully discussed in the chapter on lupus ot 
the fauces that in the present consideration we confine ourselves to 
those features of the disease which have an especial bearing on the 
laryngeal invasion. 

Etiology. — As already stated, the large majority of cases of lupus 
in the air tract develop secondar- 
ily to cutaneous lupus. After the 
fauces are invaded, the progress 
of the disease is usually from 
above downward, progressively in- 
volving the pharynx and larynx. 

The primary invasion of the 
larynx is by no means such a rare 
occurrence as has been supposed, 
cases of primary laryngeal lupus 
having been reported by many ob- 
servers. A single instance of this, 
also, has come under my own ob- 
servation: that Of a VOUng man, ^a. 145,-Lupus of the Larynx (author's case] 

aged twenty-eight, in whom the disease at the end of three and a half 
years had destroyed about two-thirds of the epiglottis and had in- 
filtrated the ary-epiglottic fold and commissure (see Fig. 145). He 
suffered no special discomfort from the disease, other than in the 
vocal impairment. There was no involvement either of the skin or 
other portions of the air tract. 

Symptomatology. — The invasion of the larynx involves symptoms 
mainly referable to the voice and respiration. Pain in deglutition 
may occasionally be present. The voice is impaired according as 
the disease invades the ventricular bands, the commissure, or the 
true cords. The encroachment upon the breathing-space, giving, rise 
to dyspnoea, is usually the most serious symptom which occurs, and 
it may even result in death from suffocation. A laryngeal stenosis 
seems also to have been a prominent symptom in some cases. In the 




694 DISEASES OF THE LARYNX. 

majority of instances, however, the disease expends itself in a slow 
but surely progressive destruction of tissue, rather than in tumefac- 
tion with encroachment upon the breathing-space. When stenosis 
occurs, it is dependent upon the infiltration of tissue only. 

Diagnosis. — The recognition of the disease is based on the same 
general rules as those already given in the discussion of the faucial 
disease. It usually attacks primarily the epiglottis, and slowly ex- 
tends downward to the ary-epiglottic folds and ventricular bands, pro- 
ducing thickening of tissue, distortion of contour, and impairment 
of function. 

Prognosis. — Lupus of the larynx is characterized by the same 
chronicity which attends a similar process in the parts above, and 
practically the prognosis is the same, except so far as it involves the 
danger of laryngeal stenosis and death from suffocation. Regarding 
this latter as a danger easily averted by tracheotomy, the disease 
is not one which involves any great danger to life. 

Treatment. — The general indications for treatment have already 
been sufficiently discussed in the previous chapter on " Lupus of the 
Fauces." As regards the laryngeal disease, nothing further need be 
said, other than the suggestion that when dyspnoea becomes in any 
way a prominent symptom a tracheal tube should be inserted with- 
out unnecessary delay. 

A laryngeal stricture as the result of lupus would seem to consti- 
tute a form of stenosis particularly favorable for the use of dilating 
bougies, in that the tissue is tolerant, and, if observed before exten- 
sive cicatrization has occurred, not very dense or resisting. A case 
of Ganghofner was treated by the solid stick of nitrate of silver and 
the galvano-cautery, and at the same time subjected to a systematic 
course of dilatation by Schroetter's bougies. He regards the steno- 
sis as having been thoroughly overcome at the end of two months. 



CHAPTER LXXXVIII. 

NEUKOSES OF THE LAKYNX. 

In the consideration of laryngeal neuroses we are confronted at the 
outset with no little difficulty in deciding upon a definite classifica- 
tion. We shall therefore simply group our neuroses according to the 
clinical manifestations, as follows : 

Hyperesthesia. 

Undue sensibility of the larynx occurs in connection with acute 
laryngitis and other inflammatory affections of the organ, and thus 
frequently in connection with chronic catarrhal processes. It is an 
especially prominent feature of laryngeal phthisis and in some cases 
of carcinoma. In syphilis, on the other hand, the sensibility is usu- 
ally diminished. It also occurs in connection with chronic catarrhal 
pharyngitis, and is especially common in the pharyngitis which re- 
sults from the intemperate use of alcohol. The reflex sensibility of 
the larynx varies notably in different individuals, and a certain 
amount of hyperesthesia may occur in individuals of a peculiarly 
nervous temperament. In the very large majority of instances, how- 
ever, it is purely symptomatic, and possesses no points of special 
clinical interest as an independent affection. 

Anesthesia. 

Complete abolition of sensation in the larynx can be due only to 
some involvement of the superior laryngeal nerve, although dimin- 
ished sensibility is not infrequently met with in chronic inflamma- 
tory processes of long standing. It also occurs in syphilis, and may 
be one of the sequelae of diphtheria. The tolerance of instrumenta- 
tion in hysterical females in well known. It may also be present in 
the general paralysis of the insane, in cases of tumor at the base 
of the brain, the early stages of tabes dorsalis, and other affections of 
the medulla. 



696 DISEASES OF THE LARYNX. 



Paresthesia. 

By this term we designate certain perverted sensations, such as 
tickling, irritation, a constant desire to swallow, or the feeling as of 
a foreign body impinging upon the parts. Undoubtedly, in the large 
proportion of these cases a careful investigation will reveal some or- 
ganic lesion to account for the symptoms, such as an hypertrophied 
lingual tonsil, enlarged pharyngeal glands, a morbid condition of the 
naso-pharynx, cheesy matter in the faucial tonsil, etc. We constantly 
meet with cases in which a tickling, or sense of irritation, producing 
cough, is referred directly to the larynx, whereas the real source of 
the trouble lies in the passages above. Patients suffering from im- 
pairment of the general health from anaemia or phthisis are especially 
liable to these perverted sensations, as well as individuals of nervous 
temperament. In many instances they are purely imaginary, while 
in others they are dependent upon some slight morbid lesion in the 
larynx or other portion of the air tract. 

Neuralgia. 

While pain referable to the region of the larynx is by no means 
an uncommon symptom, in most instances it can be traced directly 
to some morbid lesion of an organic character, either in the larynx it- 
self or in the adjacent passages. It may also be due to anaemia, rheu- 
matism or gout, phthisis, and carcinoma. In a case under my care 
the source of the difficulty seemed to be an attack of acute nasophar- 
yngitis. The prominent neuralgic symptoms were explained by the 
fact that the patient was of an intensely nervous habit. He was com- 
pletely relieved by the administration of aconitia, one five-hundredth 
of a grain every two hours, until the characteristic symptom of ting- 
ling in the fauces was produced. In this case the laryngeal pain 
seemed to have been purely neuralgic in character, being paroxysmal. 

The promineDt indication for treatment of neuralgia of the larynx, 
as well as of hyperaesthesia and paraesthesia, consists in the removal 
of such contributing causes as can be discovered in any portion of 
the air tract. 

Paralysis of the Superior Laryngeal Nerve. 

This nerve supplies sensory innervation to the mucous membrane 
lining the larynx, and motor innervation solely to the crico-thyroid 
muscle, and in part to the arytenoideus. Complete superior laryn- 
geal paralysis, therefore, would result in an abolition of sensation of 



NEUROSES OF THE LARYNX. 



697 



the mucous membrane of the laryngeal cavity, while at the same time 
the tension of the cords and the approximation of the arytenoid car- 
tilages would be seriously impaired. 

The disease may involve either one or both sides of the larynx. 
In the latter instance it produces paralysis of the tensor muscles of 
the larynx as well as of the arytenoideus, together with impaired sen- 
sation. When the affection is unilateral, however, the arytenoideus 
paralysis is usually not apparent. 

The diagnosis will depend upon a careful analysis of the laryn- 
geal movements as seen by the laryngoscopic mirror, together with a 
testing of the sensation of the parts by the introduction of a probe. 

I know of no lesion which will produce the curious glottis which 





Fig. 146.— Bilateral Paralysis of the Superior 
Laryngeal Nerve. 



Fig. 147.— Unilateral Paralysis of the Superior 
Laryngeal Nerve. 



is observed when both the superior laryngeal nerves are paralyzed, 
viz. , that in which the chink is divided by the approximation of the 
tips of the vocal processes. If the paralysis is unilateral, the larjru- 
goscopic image simply shows a relaxed condition of that portion of 
one of the vocal cords which extends from the vocal process to the 
thyroid cartilage. This condition might be the result of paralysis 
of the crico-thyroid muscle. The impairment or absence of sensation 
in the lining membrane of the larynx in such a case should indicate, 
however, a lesion of the superior laryngeal nerve. 

These cases generally recover; the duration of the affection, how- 
ever, is dependent on its exciting cause. If it follows diphtheria we 
may anticipate complete recovery at the end of from one to two 
months. In a case of section of the nerve, complete restoration of 
voice does not seem to have occurred until the end of about twelve 
months. 

The treatment of the affection consists in the administration of 



698 DISEASES OF THE LARYNX. 

general tonics, strychnia, friction, massage, and local faradization, 
with such general hygienic measures as may seem to be indicated. 



Kecurrent Laryngeal Paralysis. 

This nerve supplies motor innervation to all the muscles of the 
larynx except the crico-thyroid. As the result of its paralysis, there- 
fore, we have practically a complete abolition of motion on the side 
of the larynx involved; for although, as we know, the contractility 
of the crico-thyroid muscle is still preserved, yet, when all the other 
muscles of the larynx are paralyzed on that side, it is practically im- 
possible for the crico-thyroid to exert any appreciable influence. 

Etiology. — In the very large majority of cases which come under 
our observation, this affection is due to pressure exerted upon the 
nerve trunk in some portion of its course. On the left side, passing, 
as it does, around the arch of the aorta, it seems to be exceedingly 
liable to become involved in aneurismal dilatations of this vessel. 
Our first suspicion always, in discovering a left recurrent paralysis, 
especially in a patient in the later years of life, is that it may be due 
to aneurism. While this latter affection not infrequently gives rise 
to it, it is probably a mistake to regard it as the most frequent cause. 

We find that this form of paralysis may occur as the result of cen- 
tral lesion, lesion of the trunk of the nerve, or from peripheral 
causes. 

In a number of reported cases in which the paralysis was due to a 
central lesion, and in which post-mortem examinations were made, 
extensive destruction of the medulla was found, involving the pyra- 
mids, the olivary bodies, the restiform bodies, and the floor of the 
fourth ventricle. The central lesion may be either hemorrhage, em- 
bolism, endarteritis, disseminated sclerosis, or the ascending sclero- 
sis of locomotor ataxia. In most instances, probably, this latter form 
of disease gives rise to abductor paralysis of one or both sides, and 
yet cases of right recurrent laryngeal paralysis occurring in connec- 
tion with locomotor ataxia have been reported, as well as cases in 
which the paralysis was on the left side. 

That form of paralysis which is due to lesion of the nerve trunk 
is probably the most frequent of all, and occurs in the majority of in- 
stances on the left side. It is the result of pressure from aneurism, 
enlarged lymphatic glands, or other neoplastic development in the 
course of the nerve, such as mediastinal tumors, cancer of the 
oesophagus, etc. 

The pleuritic adhesions which develop in incipient phthisis may 
give rise to pressure on the nerve, causing paralysis. This usually 



NEUROSES OF THE LARYNX. 699 

occurs on the right side, the pleura extending somewhat higher on 
this side than the left. Instances are on record in which the paraly- 
sis was the result of a serous effusion in the pleural and pericardial 
cavities, and which promptly disappeared on the resorption of the 
serum. In the reported cases of this form of paralysis which fol- 
lowed diphtheria, typhoid fever, and other of the exanthemata, the 
lesion, as in other forms of paralysis following these affections, was 
primary and the result of the blood poison, exciting a neuritis and 
involving the nerve centres, the nerve trunk, or the terminal fila- 
ments. The local inflammatory process, however, exercises an un- 
doubted influence. In two of my own cases there was an ephemeral 
paralysis of the recurrent nerve, occurring in acute naso-pharyngitis 
accompanied by laryngitis. We can only suggest in regard to these 
that the terminal filaments of the nerve were involved in the local 
morbid process. As a rule, a double recurrent paralysis will be ac- 
cepted as evidence of central lesion, although it may occur, of 
course, from coincident pressure on both nerve trunks. Cases are 
reported in which pressure upon the pneumogastric nerve of one 
side has given rise to bilateral paralysis of the recurrent nerve. It is 
quite possible in these cases that the pressure on the pneumogastric 
sets up organic changes of the nerve centre, and that in this way the 
double paralysis really resulted from a central lesion. 

Pathology. — The degenerative changes which take place in the 
nerve as the result of paralysis are simply those which occur from a 
permanent interruption of the nerve current, either from pressure on 
the trunk or destruction of the centre. These degenerative changes 
also extend to the muscular structures which are supplied by the 
nerve, which undergo atrophy simply from their inactivity. 

Symptomatology. — If the paralysis is unilateral, its onset is 
marked by a notable degree of impairment of the voice, which be- 
comes weakened rather than hoarse. The cord of the paralyzed side 
lying in the cadaveric position, increased effort is demanded on the 
part of the muscles of the opposite side to bring the vocal cord into 
position for phonation. Hence, the mere effort at talking becomes 
exceedingly wearisome. After a few weeks, however, the cord of the 
opposite side is finally so trained, as it were, that it can be brought 
around into apposition with its paralyzed fellow, in such a way that 
ordinary conversation is carried on with ease. The cord of the para- 
lyzed side, however, is somewhat relaxed ; hence, prolonged conver- 
sation becomes something of an effort, while the range of voice is 
necessari^ impaired. As a rule, after a unilateral recurrent laryn- 
geal paralysis has existed for some months, it is impossible to detect 
in ordinary conversation any symptom which would call attention to 



700 



DISEASES OF THE LARYNX. 



an impairment of laryngeal innervation. If, on the other hand, the 
paralysis is bilateral, the voice is completely lost. The cords re- 
maining widely separated in the larynx, the setting up of vibrations 
becomes an impossibility. The patient talks in a labored whisper, 
and, as the air escapes so rapidly through the glottis, the patient is 
compelled to stop and recover his breath at the end of every two or 
three words. 

Any other symptoms which attend this form of paralysis, whether 
unilateral or bilateral, such as dyspnoea, cough, etc., must be attrib- 
uted to other conditions than the simple laryngeal paralysis, this lat- 
ter really being, as we see in the 
very large majority of instances, 
merely a symptom of some other 
more serious affection. 

Diagnosis. — The existence of 
this form of paralysis is easily rec- 
ognized on laryngoscopic examina- 
tion. If both sides of the larynx 
are affected, the cords are seen ly- 
ing motionless in a position mid- 
way between adduction and extreme 
abduction; in other words, in the 
cadaveric position (see Fig. 148). 
The only affection with which it 
can be confounded is a bilateral 
paralysis of the adductors, in which 
both cords are observed widely separated and burying them- 
selves, as it were, in the lateral walls of the larynx. The difference 
in the laryngeal images lies mainly in the fact that in adductor pa- 
ralysis the cords are not only more widely separated, but the vocal 
jjrocesses are swung outward in such a way as to produce a some- 
what concave appearance of the vocal cords, while in the cadaveric po- 
sition the vocal process is seen slightly projecting in the direct line 
between the arytenoid and the receding angle of the thyroid. If the 
paralysis is unilateral, the vocal cord of the affected side will be seen 
lying in the cadaveric position, while that of the healthy side will be 
found moving not only throughout its normal arc, but in adduction 
passing beyond the median line and swinging over to meet its fellow, 
for purposes of phonation. In this act the arytenoid cartilage of the 
healthy side passes slightly in front of the opposite cartilage, as seen 
in Fig. 149. 

The diagnosis will depend, then, on this peculiar position of the 
two arytenoids during phonation with reference one to the other, and 




Fig. 148.— Cadaveric Position of the Cords, 
as in Bilateral Paralysis of the Recurrent 
Laryngeal Nerve. 



NEUROSES OF THE LARYNX. 



701 



tlie obliquity of the rima glottidis, which is deflected from before 
backward toward the paralyzed side. This is easily seen if the lar- 
yngeal mirror be so arranged in the fauces that the centre of the crest 
of the epiglottis is brought in a directly straight line with the centre 
of the arytenoid commissure during inspiration. If, now, the pa- 
tient be directed to phonate, the narrowed chink of the glottis will be 
seen in an oblique line, while at the same time the cord of the para- 
lyzed side will be observed to lie motionless in the cadaveric posi- 
tion. It is to be borne in mind always, in making this examination, 
that not infrequently we meet with an epiglottis standing so ob- 





Fig. 149. 



-Right Recurrent Paraljsis during 
Pho nation. 



Fig. 150. 



-Right Recurrent Paralysis during 
Inspiration. 



liquely that the centre of its crest will deviate several degrees from the 
median line. Curiously enough, if we align the laryngeal mirror with 
an oblique epiglottis, we will get an exceedingly deceptive laryngo- 
scopy image, and one which will oftentimes give the appearance of 
recurrent paralysis. In such a case we adjust our mirror in the me- 
dian line of the fauces by the eye, aligning it upon the soft palate 
and pharynx. 

Having discovered a laryngeal paralysis, we must endeavor to as- 
certain its cause. This will involve a most careful inspection and ex- 
amination of the thoracic organs by means of auscultation and per- 
cussion, of the cervical region by palpation and inspection, and of the 
nervous system by close questioning and other tests. 

Prognosis. — If the disease is the result of peripheral neuritis, as 
in diphtheria, one of the exanthems, or an attack of acute inflamma- 
tion, recovery from the j)aralysis may be anticipated in the course of 
from three to six weeks. If, on the other hand, it is due to pressure 
on the nerve trunk or to a central lesion, the laryngeal paralysis is 
to be regarded merely as symptomatic of the affection which has 



702 DISEASES OF THE LARYNX. 

given rise to it, and the prognosis will be decided entirely upon the 
features of the more serious affection. If the condition which has 
caused the paralysis be a curable one, the prognosis as regards res- 
toration of motility in the larynx will depend entirely upon the dura- 
tion of the laryngeal symptoms. After a paralysis has existed for 
twelve months or even longer, the conductivity of the nerve may in 
rare instances be restored ; but the muscles which this nerve has sup- 
plied undergo atrophic changes, which at the end of from six to nine 
months usually have reached such a stage that the hope of their res- 
toration becomes somewhat doubtful. 

Teeatment. — If the disease is the result of an ordinary inflamma- 
tory process of the upper air passages, this should be actively at- 
tacked by topical applications of an astringent character. If it is 
caused by diphtheria or one of the exanthems, it should be treated by 
the internal administration of general tonics and strychnine. When 
it is due to disease of the nerve trunk or centre, the indications for 
treatment will depend entirely upon the ascertained cause of the pa- 
ralysis. 

When the paralysis is the result of an aneurism or other incurable 
affection, it is idle to hope for any beneficial effect from electricity. 
When, however, there is any promise of relieving the pressure on 
the nerve trunk by the removal or dissipation of the offending tumor, 
electrical stimulation should be followed up systematically until this 
is accomplished, in the hope of maintaining the muscular structures 
in a healthy condition. This may be done by applying one pole of 
the battery to the nape of the neck, and passing the other over the 
laryngeal region in front, or, better still, into the laryngeal cavity, and 
as far as possible stimulating successively the various paralyzed 
muscles. This is accomplished with comparative ease with the aid 
of cocaine anaesthesia. The faradic current usually answers the bet- 
ter purpose. If, however, the continued current shows a better reac- 
tion, as it occasionally does, this should be substituted. 

Cases of recurrent paralysis will rarely be benefited by electrical 
stimulation. This agent so often irritates and inflames the parts and 
exhausts the patient, that it should never be used unless there is a 
very fair promise that it will be of decided benefit. 

Bilateral Paralysis of the Abductor Muscles. 

The muscular movements by which the opening of the glottis is 
accomplished during inspiration constitute what is called the respira- 
tory function of the larynx, and depends solely upon the action of the 
posterior crico-arytenoid muscles. This function, as we know, con- 



NEUROSES OF THE LARYNX. 703 

sists in the separation of the vocal cords during the act of inspira- 
tion, and is presided over by distinct nerve centres in the medulla. 
This form of paralysis, as involving both sides of the larynx simulta- 
neously, occurs in such a large class of cases that it merits considera- 
tion as an affection distinct from the unilateral form of the disease. 

Etiology. — There are three views advanced to account for this 
curious disease : 

First. — That it is due to a peripheral lesion. 

Second. — That it is due to a morbid lesion in the continuity of the 
nerve; and 

Third. — That it is due to a central lesion. 

First. — As regards the peripheral lesion: Mackenzie suggests that 
owing to the exposed situation of the abductor muscles on the poste- 
rior aspect of the larynx, they are especially liable to become the seat 
of injury, which, added to the fact of their ceaseless activity, renders 
them vulnerable ; and he thinks that this fact may act in a causative 
relation to the disease, apparently abandoning the idea that the dis- 
ease may be of cerebral origin. Gowers points out the fact that the 
abductor muscles are inserted into the arytenoid cartilages at an 
acute angle, while in the adductors this insertion is at a right angle. 
Hence, pressure affecting the nerve trunk results in a paralysis first 
of the abductors and subsequently of the adductor muscles. 

Krause seems to have reached the conclusion that the disease is 
caused by a spasmodic contraction in the laryngeal muscles. This 
spasm, furthermore, he states, may result from a morbid condition 
of the nerve centres, or it may be dependent upon a reflex irritation 
of the superior laryngeal nerve, or a direct irritation of the recurrent 
nerve. He attributes the median position of the cords in pressure 
on the nerve to the spasmodic action of the other muscles in the lar- 
ynx. The pressure on the nerve, not serving to arrest the nerve cur- 
rent, merely causes an irritation, under which spasmodic contraction 
follows in the muscles which it supplies. Some believe that confirm- 
atory evidence of the spasmodic character of the disease lies in the 
fact that the voice is not affected. That this spasmodic element has 
any bearing on those instances in which the disease has persisted for 
long periods of time I do not believe, for it is difficult to understand 
how a tonic spasm affecting a given group of muscles can persist, 
through a long period of years even, without resulting in degenera- 
tive changes which are to an extent uniform in all, for repeated inves- 
tigations have demonstrated conclusively that the abductor muscles 
are the ones which alone undergo marked atrophic degeneration. 

Second. — As to a morbid condition of the continuity of the nerve 
as a cause of the disease. Pressure on the recurrent laryngeal nerve, 



704 DISEASES OF THE LARYNX. 

or other morbid conditions which may interrupt the nerve current, 
has been a favorite theory by which the phenomena of abductor pa- 
ralysis is explained. 

Semon deduces the inference from a series of experiments that 
when the nerve current which supplies all the laryngeal muscles is 
hampered or interrupted by pressure exerted in the course of the 
nerve, the fibres which supply the abductor muscles succumb first. 
In other words, the abductor muscles in this respect are somewhat 
weaker than the other muscles of the larynx, and thus yield to the 
influence of a defective innervation, while the stronger muscles main- 
tain their contractility. 

Though experimentation has demonstrated that under electrical 
stimulation the adductor fibres show a greater vitality than the ab- 
ductors, yet I fail to see that this proves the proclivity theory of 
Semon. 

We might expect that there would exist a difference in the re- 
sponse to electrical stimulation on the part of the phonatory and re- 
spiratory muscles of the larnyx. The respiratory movements of the 
larynx are unceasing, commencing with the first breath of life and 
ending only with dissolution. The phonatory movements of the 
larynx, on the other hand, are intermittent. The respiratory move- 
ments are involuntary, the phonatory movements voluntary. These 
functions, therefore, necessarily involve certain differences in inner- 
vation. I believe that the view that the disease is due to pressure on 
the recurrent nerve, and that this pressure so far discriminates be- 
tween the nerve fibres as to destroy the conductivity of those fibres 
alone which are distributed to the abductor muscles, is quite untenable. 

Third. — As to a morbid condition of the nerve centres. 

I still hold to my opinion, expressed as follows in a former arti- 
cle upon the subject : " Beasoning from analogy, considering the 
peculiar character of the respiratory movements of the larynx in that 
they are purely involuntary and also reflex, that the opening of the 
glottis constituting the respiratory movement is an independent action 
separate from all the other movements which take place in the larynx 
as the result of muscular contractions, it is fair to conclude that this 
function is presided over by an independent ganglionic nerve centre, 
and that the disease in question consists in some degenerative change 
taking place in this portion of the nerve centres." 

This view is substantiated by the clinical history of locomotor 
ataxia or tabes dorsalis, showing that laryngeal crises, anaesthesia of 
the lining membrane of the larynx, loss of reflex irritability, and 
symptoms of paralysis of the abductor muscles are a frequent accom- 
paniment of the disease. 



XEUROSES OF THE LARYNX. 



705 



In a very large proportion of the cases in which the paralysis in- 
volves both sides we should certainly suspect the existence of some 
morbid process in the bulbar region, the laryngeal paralysis being 
accepted as evidence of this. That the disease may occur as the re- 
sult of pressure on both recurrent nerves must be conceded, in view 
of the cases reported by Semon and others; but even in these I 
think it is probable that, if a careful investigation of the bulbar re- 
gion were obtainable, some morbid process would be discovered. 

Pathology. — The various changes which occur in the nerve centres 
and in the continuity of the nerve have already been clearly indicated. 
Perhaps the most interesting feature 
of the disease lies in the fact that the 
abductor muscles themselves under- 
go degenerative changes with atro- 
phy, purely as the result of the 
interrupted nerve current. These 
changes are especially noticeable 
after the paralysis has persisted for 
a number of months, and are comple- 
ted in from six to eight months. 

Symptomatology. — The prominent 
feature of the affection consists in a 
gradually progressive development of 
inspiratory-dyspncea, which soon as- 
sumes a somewhat spasmodic char- 
acter. These attacks of inspiratory 
dyspnoea, which at the onset of the 
affection are somewhat mild in char- 
acter, gradually assume a more seri- 
ous form, and, in addition to this, 
they recur with greater frequency. 
The inspiratory character of the at- 
tacks is well marked from the first, 
and, as the paroxysms assume a more aggravated type, the act of inspi- 
ration becomes not only noisybut exceedingly labored. These par- 
oxysms of dyspnoea are finally precipitated by any slight excitement 
or effort, and may come on a number of times during the day. Ex- 
piration is in no way affected, and there is, moreover, nothing in the 
voice which would call attention to the fact that the source of the 
disease was in the larj-ngeal cavity. 

There are certain features in the gross anatomy of the larynx 
which I think in part explain the dyspnceic attacks. A transverse sec- 
tion of the larvnx will show that the upper surfaces of the vocal cords 
45 




Fig. 151.— Transverse Section of the Lar- 
ynx, illustrating the Valve-like Action of 
the Cords in Bilateral Paralysis of the 
Abductors. 



706 



DISEASES OF THE LARYNX. 



and adjacent tissues are hollowed in such a manner that they present 
a valve-like orifice when near approximation, not unlike that of the 
semilunar valves of the aorta. The ingoing current of air thus has 
a tendency to render their closure more complete when they are 
brought near together. This action will be more clearly appreci- 
ated by reference to Fig. 151. 

The clinical features of the disease, so far as the larynx is con- 
cerned, are confined to the paroxysmal attacks of dyspnoea, and any 
other symptoms which present are dependent upon the disease which 
gives rise to the laryngeal paralysis, such as a central nerve lesion, 

aneurism of the aorta, tumor of the 
mediastinum, bronchocele, enlarged 
lymphatic glands, locomotor ataxia, 
or other lesion involving either the 
nerve centres or trunk. 

Diagnosis. — The recognition of 
the disease depends upon a laryn- 
goscopy examination, which will 
show the cords lying practically 
motionless near the median line. 
During the act of inspiration, we 
find the chink of the glottis narrowed 
and the cords in a position of par- 
allelism (see Fig. 152), leaving a 
space of from one-eighth to one- 
tenth of an inch, while in expiration the rima is opened by the pres- 
sure of the outgoing current of air. During phonation, which is ac- 
complished with ease and in the normal manner, the cords are brought 
into close apposition and vibrate as in health. 

I know of no disease which presents a laryngoscopic appearance 
that can be mistaken for this form of paralysis, unless we except 
ankylosis of the crico-arytenoid joints, in which the fixed position 
occurs usually with the cords also in the median line. This form of 
ankylosis in most instances occurs in connection with some of the 
graver diseases, such as cancer of the oesophagus, tuberculous laryn- 
gitis, and in rare instances in syphilis. 

Prognosis. — This is not a disease which in itself ordinarily in- 
volves any very great danger to life, although of course in any given 
case the prognosis will depend largely on the ascertained cause of the 
affection, as bearing on the danger to life, on the hope of recovery from 
laryngeal impairment. A number of instances have been reported 
in which death from dyspnoea has occurred ; but after the insertion of 
a tracheotomy tube such patients may live apparently indefinitely. 




Fig. 152, 



-Bilateral Paralysis of the Abductor 
Muscles. 



NEUROSES OF THE LARYNX. 707 

Those cases in which the disease develops rapidly seem to afford 
the best hope of ultimate recovery. 

When the abductor muscles have been paralyzed for at least nine 
months, the degenerative changes have progressed to such an extent 
as to render a return of motility impossible. 

Treatment. — If the paralysis is due to pressure on the nerve 
trunk or to central lesion, any treatment directed to the laryngeal 
manifestation will be only a waste of time and a needless tax upon 
the patient. If a careful investigation of the case warrants the opin- 
ion that the lesion is peripheral, it becomes our duty to remove any 
inflammatory or other local condition that may be found in the mu- 
cous membrane of the larynx, while at the same time the attempt 
should be made to restore motility to the paralyzed muscles by the 
application of the electric current, by the administration of strych- 
nine, by massage, and by such other measures as may seem indicated. 

No prominent mention has been made of syphilis as a cause of the 
disease, and yet a number of instances have been observed of this 
character. The indications for treatment in a case in which its 
syphilitic origin can be determined seem perfectly clear for the ad- 
ministration of full doses of iodide of potassium. In addition to 
this, there can be no question as to the advisability of subjecting the 
paralyzed muscles to the action of either the faradic or galvanic cur- 
rent, according to the reaction which is obtained by experimental test. 

While it is doubtful if motility can be restored to a muscle after 
the paralysis has existed for a period longer than nine months, yet in 
no instance should the attempt be omitted while there seems any 
hope whatever of eliminating the cause of the affection. 

If the remedial measures are not immediately followed by an 
amelioration of the condition, as shown by an increased separation of 
the cords in inspiration, there can be no question as to the propriety 
of tracheotomy. It is certainly not wise in these cases to defer the 
operation until the dyspnceic symptoms render it absolutely impera- 
tive. The number of patients who have perished from suffocation 
clearly shows that a fatal paroxysm is liable to occur at any time; 
furthermore, this may happen when the immediately preceding symp- 
toms have not been especially urgent. Another point which argues 
in favor of an early tracheotomy is the fact that, after the laryngeal 
muscles are put at rest by a tracheal opening, we can hope for far 
better results from internal medication and local electrization than 
while the patient is suffering from the recurrent dyspnceic paroxysms. 

Krause, regarding the disease as of spasmodic origin, suggests the 
propriety of dividing the recurrent laryngeal nerve on both sides. 
The result of this would be to throw each cord into the cadaveric 



708 DISEASES OF THE LARYNX. 

position. The dyspnceic attacks would certainly be relieved, but the 
voice would be lost. 



Unilateral Paralysis of the Abductors. 

This form of paralysis differs in no essential degree from the bi- 
lateral form already discussed, except that it involves but one side of 
the larynx and therefore gives rise to a somewhat different train of 
symptoms. As in the former disease, I believe that in most instances 
it is due to a lesion of the nerve centres. 

Pressure on the trunk of the recurrent nerve has in some instances 
produced a simple paralysis of abduction, without involving the other 
muscles supplied by this nerve. 

In rare cases the disease may be the result of peripheral condi- 
tions, such as acute inflammatory or other processes in the laryngeal 
cavity. Among other possible causes may be enumerated gout, rheu- 
matism, lead poisoning, typhoid fever, diphtheria, and the other 
exanthemata. 

During phonation the laryngoscopic image differs in no degree 
from the normal, the cords being perfectly approximated in the me- 
dian line. During inspiration, however, the cord of the affected side 
remains motionless, while its fellow is abducted in its normal arc. 
The only form of paralysis with which it can be confounded is that of 
the recurrent nerve involving one side, in which the cord assumes the 
cadaveric position. In the latter disease the cords are approximated, 
but the chink of the glottis runs in an oblique direction from before 
backward, while at the same time the arytenoid cartilage of the mov- 
able side is brought in front of its fellow. In the disease under con- 
sideration, the chink of the glottis during phonation is in perfect 
alignment from in front backward. 

The symptoms directly referable to the laryngeal condition are 
so little marked that many of these cases have been discovered 
accidentally. 

In a number of cases reported dyspnoeic symptoms have been 
present; they are never paroxysmal in character, but constitute sim- 
ply a shortness of breath on exertion. This probably is the result of 
the disease which causes the paralysis, such as a bronchocele, an 
aneurism, or other tumor pressing on the nerve trunk. 

To what extent a unilateral abductor paralysis is to be regarded 
as the precursor of the bilateral form, it is perhaps not easy to deter- 
mine. The possibility of this danger, certainly, is to be borne in 
mind. 

The indications for treatment of this form of the disease are prac- 



NEUROSES OF THE LARYNX. 709 

tically the same as those already discussed in connection with the 
double abductor paralysis, with the exception, of course, that tra- 
cheotomy for the relief of dyspnoea is never demanded. 

Paralysis of Individual Muscles. 

In this group we consider those instances in which impairment 
of motility is observed in the various other muscles of the larynx not 
already considered, and in which the lesion is the result purely of 
myopathic causes. 

These cases do not occur frequently, with the exception perhaps of 
paralysis of the arytenoideus muscle. In the very large majority of 
instances they result from local inflammator}- processes, either of an 
acute or chronic character, invading the mucous membrane of the 
larynx. In other cases they may be dependent upon over-use or 
straining of the voice. When met with in cases of syphilis and tuber- 
culosis and other grave lesions of the larynx, they are to be regarded 
as purely adventitious in character. 

When it occurs in connection with anaemia, malaria, gout, or rheu- 
matism, the laryngeal lesion is due, I think, to the fact that the mus- 
cles are weakened by some local inflammatory process set up by the 
general condition, under the influence of which muscular contractility 
is destroyed by some over-use or strain of the voice. "Hysterical 
aphonia," will be considered later, as constituting a paretic rather than 
a paralytic condition. 

The causation of all these so-called myopathic paralyses is prob- 
ably the same ; the other features of the affection require separate 
consideration. 

Unilateral Adductor Paralysis. — I have never seen a case in which 
I felt warranted in making a diagnosis of this form of paralysis, 
though its occurrence has been occasionally reported, and I fully 
agree in the assertion that it requires an exceedingly expert eye to 
draw a distinction between the position of the cord in extreme abduc- 
tion and the cadaveric position. 

That this condition may occur as the result of injury of the pneu- 
mogastric I cannot accept, nor do I believe that paralysis of this 
muscle can occur from any known lesion of the central or peripheral 
nervous apparatus. In the nature of the case, it must be purely of 
a myopathic character, in which form it has been observed to follow 
lead poisoning, diphtheria, exposure to cold, etc. 

The only symptoms which are the direct result of the laryngeal 
lesion are either impairment or complete loss of voice. 

Laryngeal examination will show one or the other cord lying 



710 



DISEASES OF THE LARYNX. 



motionless in a position of extreme abduction. During phonation, 
the cord of the opposite side is brought around as far as possible 
toward its motionless fellow, its arytenoid thus coming more or 
less completely in front of the other. It is difficult to diagnose 
between this condition and that of recurrent laryngeal paralysis, in 
which the cords assume the cadaveric position. Certain contributive 
evidences will be afforded by the condition of the tensor muscles, 
which of course are not affected in simple abductor paralysis. 

Bilateral Adductor Paralysis. — I know of no cases of this form of 
the disease, other than the five reported by Mackenzie. They may 

have been hysterical in character, 
however, as in each instance there 
was noticeable movement in both 
cords. A genuine myopathic pa- 
ralysis involving the lateral crico- 
arytenoid muscles might occur as 
the result of exposure to cold, lead 
poisoning, diphtheria, scarlet fever, 
or some other of the exanthemata. 
It would give rise to complete loss 
of voice, with phonatory waste, as 
already described in the discussion 
on double recurrent laryngeal pa- 
ralysis, from which disease I know 
of no method of distinguishing it by laryngoscopic examination. 

Paralysis of the Internal Tensors. — This is by far the most common 
and most easily recognized of all forms of myopathic paralysis, and 
is the result of an impairment of contractility in the thyro-aryte- 
noideus muscle, which, lying as it does immediately beneath the 
mucous membrane on the under surface of the cords, thus becomes 
liable to involvement in such morbid processes of an inflammatory 
character as invade this region. In this way it occurs commonly in 
connection with chronic laryngitis, although the direct exciting cause 
in most instances is the result of overstrain or prolonged use of the 
voice. 

The symptoms are practically confined to phonation. The voice 
is not only weakened, but its range materially diminished, the im- 
pairment being more marked in the use of the higher notes. The 
ordinary conversational voice may not be impaired, although, if the 
muscular weakness is marked, these tones are lowered and approach 
somewhat in character to the whispered voice. 

In most instances the affection is bilateral, although it may be 
confined to a single cord. 




Fig. 153.— Paralysis of Left Internal Tensor. 



NEUEOSES OF THE LARYXX. 



711 



It is easily recognizable on laryngoscopic inspection. During 
phonation, the rima, instead of presenting the narrow, straight chink 
as in life, presents an elliptical opening. This is not the effect of a 
lateral separation of the cords, but is due to the fact that, in forcing 
the current of air through the chink, the cords belly upward in such 
a way as to present the appearance of an elliptical opening (see Fig. 
153). This ellipse involves the whole length of the cord. If the pa- 
ralysis confines itself to one side, it gives rise to practically the same 
train of symptoms with reference to the voice. Paralysis of the crico- 
thyroid muscle, as we have seen, gives rise to impairment of phona- 
tion and an elliptical or semi-elliptical glottis ; but in this case the 
ellipse extends only from the receding angle of the thyroid cartilage 
to the vocal process. Moreover, the vocal cord, as we know, is prac- 
tically a tendon of the thyro-aryte- 
noideus muscle. If this latter is 
paralyzed, the vocal band assumes a 
narrowed and cord-like appearance ; 
whereas if it is intact, it presents a 
somewhat broad and flat upper sur- 
face, even when the tensor action 
of the crico-thyroid is ablated. 

Paralysis of the Arytenoideus. — 
This muscle is especially liable to 
become involved in chronic catar- 
rhal processes in the larynx, of long 
standing. Incipient phthisis, diph- 
theria, hysteria, and severe expo- 
sure have all been noted as causes 
of the disease. The voice becomes very seriously impaired, or even 
completely lost, from the fact that during the attempt at phona- 
tion only that portion of the glottis is closed which extends from the 
thyroid angle to the vocal processes, while behind these points a some- 
what wide triangular opening is left, as seen in Fig. 154. The voice 
is either hoarse or completely lost, while the air escapes through this 
triangular opening during the attempt at phonation, to such an extent 
that conversation becomes fatiguing, and a frequent recovery of the 
breath becomes necessary. 

Laryngoscopic examination clearly indicates the condition, the 
rima being practically normal in its anterior two-thirds, while the 
posterior third is found widely apart. 

As we have already seen, this condition may occur as the result of 
a bilateral paralysis of the superior laryngeal nerve, but in the latter 
case there is also a paralysis of the crico-thyroid muscles, by which 




Fig. 154. 



-Paralysis of the 
Muscle. 



Arytenoideus 



712 DISEASES OF THE LARYNX. 

the glottis presents an elliptical opening extending from the vocal 
processes to the thyroid angle. 

Prognosis in Myopathic Paralysis. — The only grave symptom 
which attends a paralysis of any of the individual muscles of the 
larynx confines itself entirely to the question of restoration of voice. 
The longer the disease has existed, the less hope there is of com- 
plete recovery. On the other hand, when the disease depends upon 
some simple exposure or is the sequel of diphtheria or one of the 
exanthems, the tendency is toward spontaneous recovery. Paralysis 
of the internal tensors is perhaps the most obstinate of all these af- 
fections, in that the absolute rest which is demanded is exceedingly 
difficult to enforce. In most instances, probably, the hope of re- 
covery will depend somewhat on the success of treatment directed to 
the removal of local lesions. 

If a myopathic paralysis develops in connection with incipient 
phthisis, a natural suspicion would be excited of the presence of some 
tuberculous process in the organ. The simple anemia or impaired 
general nutrition which accompanies this disease may predispose to 
the paralysis, however, in which case it should be overcome by proper 
measures. 

Treatment. — The first indication is in the removal of such local 
lesion as may exist in the larynx, while at the same time such abso- 
lute rest of the parts is secured as may be possible. All prolonged 
or loud use of the voice is to be absolutely forbidden, and it may be 
well even to direct the patient for a while to carry on all conversation 
in the whispered voice. 

For the restoration of the impaired muscle, we possess no remedy 
better than the application of the electric current. In most instances, 
the faradic current will afford the best results, although, if any given 
case fails to respond promptly to this, trial should be made of the 
continuous current. The applications should be made directly 
through the paralyzed muscle, as far as possible. Ziemssen's elec- 
trodes answer an excellent purpose in these cases. In using the sin- 
gle instrument one electrode is introduced into the larynx, while the 
other pole is applied directly over the larynx externally ; the double 
electrode is devised for more direct application of the current to the 
muscle within the laryngeal cavity. These applications should be 
made every day, the sittings lasting from ten to fifteen minutes until 
a notable result is obtained, when the intervals may be prolonged. 

This treatment is undoubtedly much aided by the internal admin- 
istration of strychnine, while special attention should be directed to 
the general health, and iron and general tonics administered accord- 
ing to indications. Outdoor life, with a sufficient amount of exercise 



NEUROSES OF THE LARYNX. 713 

and, if tolerated, the daily use of the cold bath with friction of the 
skin, should be enjoined, together with such other general hygienic 
measures as may seem wise. 

Hysterical Aphonia. 

This term is used to designate a form of aphonia which is charac- 
terized by a complete loss of voice, and which is purely functional in 
character. It is sometimes designated as hysterical paralysis of the 
vocal cords, and again as functional paralysis. The important point, 
and the one to be emphasized in the consideration of this affection, 
is that, while the condition is one that can always be assumed under 
voluntary effort, it is still one which is assumed by the patient under 
the influence of a strange psychical condition, or by whatever other 
term we may choose to designate it, and not one which the patient 
wilfully assumes with the desire to deceive or to excite sympathy. 

Furthermore, hysterical aphonia or paralysis counterfeits only 
those forms of paralysis which can be assumed by voluntary effort. 
Abduction of the cords being purely an involuntary motion, and oc- 
curring only during the act of inspiration, paralysis of the abductors 
is not met with as a functional or hysterical paralysis. A unilateral 
paralysis of the vocal cords can never occur as a hysterical or func- 
tional affection. The condition seen is that of imperfect approxima- 
tion of the cords, resembling somewhat the condition which we meet 
with in double paralysis of the recurrent nerve. The patient does, 
however, adduct the cords to a slight degree, and the sound produced 
by the passage of air through the partially closed rinia glottidis is 
transformed into articulate speech by the lips and tongue, etc. The 
voice is lost, and the patient simply communicates in a whisper. 
The affection under consideration may simulate subacute or acute 
laryngeal catarrh ; but the laryngeal examination will reveal the nor- 
mal mobility of the cords, and, in addition, the source of the aphonia 
in the catarrhal inflammation of the mucous membrane lining the 
larynx, accompanied by swelling of the membrane covering the cords. 
Those cases of aphonia due to mechanical interference with the prop- 
er closure of the cords on account of thickening of the mucous mem- 
brane covering the arytenoids or the commissure may also be simu- 
lated, but will be easily recognized. The hysterical affection may 
resemble double paralysis of the recurrent laryngeal nerves ; in this 
disorder, how r ever, all the muscles of the larynx are completely par- 
alyzed, the cords are absolutely motionless and in a position midway 
betw r een extreme adduction and abduction. This position of the 
vocal cords cannot be assumed or simulated, for the instant that in- 



714 DISEASES OF THE LARYNX. 

spiration occurs the glottis will be widened and movement can be 
seen to take place. Hysterical paralysis is always bilateral, and 
always assumes the form of incomplete closure of the glottis. 

A careful study of the larynx will clear up the diagnosis of these 
cases and enable the physician to determine that the aphonia is a 
functional disorder, and not due to any pathological lesion, simply by 
exclusion; for, as a rule, the laryngeal image does not and will not 
present a complete picture of any of the forms of genuine paralysis. 
There will also be accompanying evidences of the hysterical tempera- 
ment. It should be added that cough is present in hysterical aphonia, 
while in genuine paralysis of the adductors it is entirely lost, the 
possibility of a cough being dependent on the ability to close the 
glottis. Furthermore, this form of laryngeal paralysis comes on 
without any previous warning whatever. The test which can be re- 
lied on with great certainty for diagnostic purposes is the adminis- 
tration of an anaesthetic. During the stage of excitement the patient 
will break into a very satisfactory use of the voice. The victims of 
this disorder are women from fifteen to forty -five years of age, and 
most frequently those unmarried, or those in whom the sexual life 
has been perverted. 

Treatment. — It is utterly unsafe to treat these cases as unreal or 
as dishonest. So far as the patient is concerned, the paralysis is a 
genuine paralysis, as much so as if the trunk of the nerve were 
destroyed. It is, therefore, necessary to treat it as a real paralysis, 
by the removal of any exciting causes, such as uterine disease, etc., 
and by resorting to local treatment ; the end in view is to convince 
the patient that she can use her voice. One way of accomplishing 
this is by resort to local measures of treatment for the relief of the 
morbid condition which she believes to exist, securing the patient's 
confidence and assuring her that at some designated time the com- 
plete restoration of the voice will be effected. In one case, a pro- 
found impression was made on the patient by the preparations for 
tracheotomy, with the result of completely removing the paralysis. 

Spasm of the Glottis. 

By this term we designate that sudden closure of the aperture of 
the larynx as the result of which the entrance of air is more or less 
completely shut off during the persistence of the attack, excluding the 
so-called cases of laryngismus stridulus. 

The later writers seem to be divided somewhat between the teach- 
ing that the disease is due to central origin, or involvement of the 
motor nerves of the larynx, and the view that it is reflex in character. 



NEUROSES OF THE LARYNX. 715 

It is a mistake to suppose that all cases can be assigned to any 
one lesion. As the affection presents features which differ greatly in 
infancy and in adults, it seems wise to consider it under two heads. 

Spasm of the Glottis in Children. 

That a neuropathic laryngeal spasm should occur in children, and 
that it should also be more common than in adult life, is quite easy 
to understand. 

Etiology. — Rachitis seems to be the more common cause of the 
disease. Whether this is due to softening of the occiput, or to im- 
paired nutrition, it is difficult to say. Probably, the latter is the 
correct view, as it is liable to occur in children whose health is under- 
mined by improper food, bad hygienic surroundings, insufficient 
clothing, and other circumstances of this kind. With these predis- 
posing causes, the attack is liable to be set up by any condition which 
might give rise to reflex disturbances in young children, such as pro- 
longed crying, exposure to cold, an attack of whooping cough, denti- 
tion, or gastric or intestinal disturbances. That pressure on the 
laryngeal nerves, from enlarged bronchial or tracheal glands or an- 
other cause, may give rise to the disease cannot be questioned. In 
most instances, it is met with between the ages of one and eighteen 
months, and is more common among boys. 

Pathology. — The paroxysm is the result of a spasmodic contrac- 
tion of the thyroarytenoids, the lateral crieo-arytenoids, and the 
arytenoideus. The glottic closure may also be due to paralysis of the 
posterior crico-arytenoid muscles. 

The primary impulse which sets up the laryngeal spasm may 
originate in the cerebrum, in the motor centre of the larynx in the 
medulla, or it may arise reflexly from some local disturbances in the 
larynx, or in the intestinal canal, or, in fact, in any portion of the body. 
Underlying these is the impoverishment of the blood, with a result- 
ant impairment of nutrition of the nerve centres. 

Symptomatology. — The attack comes on suddenly and without 
warning. A child giving no evidence whatever of a local disturbance 
in the larynx is suddenly seized with an attack of dyspnoea of an in- 
spiratory character, which may last at first only a few seconds or at 
the utmost from two to three minutes, when the symptoms subside. 
The paroxysm is attended with characteristic sonorous inspiration. 
The seizure generally occurs at night, the child starting up in bed, 
struggling for breath, and rapidly becoming cyanotic. The spas- 
modic character of the attack is also shown by the fact that the glottis 
is narrowed not only during the inspiratory act, but also during the 



716 DISEASES OF THE LARYNX. 

expiratory act, as evidenced by the obstructive sound which accom- 
panies the latter. In certain cases the glottis is completely closed at 
the onset of the attack, so that both inspiration and expiration for 
the time are completely arrested. This may persist for from ten to 
twenty seconds, when the muscular contraction yields somewhat, al- 
lowing a limited amount of air to pass, although the dyspnoea may 
persist for some minutes even. 

The attacks may recur at varying intervals, several taking place 
within twenty-four hours, or several days may elapse before a recur- 
rence of the attack. In general, the tendency is toward an increase 
both in frequency and severity of the seizures. This may persist for 
a few weeks, when the attacks recur with a somewhat unvarying 
severity for a certain period, which is followed by a gradual amelio- 
ration of the symptoms. In other cases, the severity of the attack 
and the duration of the spasm may increase to such an extent that 
the child finally perishes from suffocation during an especially ag- 
gravated seizure. Even when there has been a notable improvement 
in all the symptoms, and when the attacks have apparently ceased for 
a considerable period of time, under the influence of some slight ex- 
posure, or perhaps an inflammatory attack involving the upper air 
tract, a relapse may take place in which a paroxysm may occur fully 
as grave as any previous attack. 

In connection with laryngeal spasm, the child shows other evi- 
dences of irritation of the nerve centres, in the twitching of the limbs, 
extension of the feet, and clenching of the hands, while diaphrag- 
matic spasm is not uncommon. 

If the disease has persisted for some time, the child shows notable 
evidences of impaired nutrition. This is in part the result of rachitic 
habit or such general condition as may have given rise to the disease, 
but in no small degree to the disturbed sleep and. the severe tax on 
the general nervous system. 

Diagnosis. — Other diseases in young children are characterized 
by spasmodic attacks. A neoplasm gives rise to progressive dyspnoea, 
with impairment or complete loss of the voice. The spasm which 
occurs in these cases is a rare symptom, is somewhat mild in charac- 
ter, and is completely masked by the suffocative attacks, which are 
patently the result of some mechanical obstruction involving both in- 
spiration and expiration. Instances of bilateral paralysis of abduc- 
tion which commenced in childhood have been reported. In this dis- 
ease the affection runs a more chronic course, the paroxysms of 
dyspnoea are longer and of not so severe a type ; furthermore, evi- 
dence of that rigidity of the glottis which gives rise to both inspira- 
tory and expiratory dyspnoea in true spasm is wanting. In addition 



XEUROSES OF THE LARYNX. 717 

to this, in true spasm of the larynx we usually meet with convulsive 
movements in some other portions of the body. The disease with 
which laryngeal spasm is most likely to be confused is subglottic 
laryngitis, the clinical history of which is in most instances marked 
by recurrent attacks of spasmodic dyspnoea, which usually occur at 
night. Moreover, there is a certain progressive element in it, and 
it is accompanied by the usual train of catarrhal symptoms. The 
dyspnceic attacks are almost purely inspiratory in character. An at- 
tack of true spasm of the glottis is not infrequently precipitated by 
a catarrhal laryngitis, but it is usually of a mild type, and is not 
characterized by any prominent symptoms other than the loss of 
voice ; whereas a subglottic laryngitis is attended by febrile disturb- 
ance, the peculiar croupy cough, and a certain amount of secretion. 

Prognosis. — The disease is an exceedingly grave one, and the very 
large proportion of cases terminate fatally. In any given case the 
prognosis is unfavorable according to the severity of the attack, the 
shortness of the interval between the paroxysms, and the extent of 
impairment of the general health. 

Treatment. — If the child is seen during the paroxysm, prompt 
measures should be taken to curtail its duration as far as possible hy 
an abundance of fresh air, placing the child in a semi-recumbent posi- 
tion, loosening the clothing, applying sinapisms to the back of the 
neck, immersing the feet in hot water, -and applying cold compresses 
to the head. The object of these measures is to diminish the blood 
pressure on the centres of laryngeal innervation. Any attempt to 
administer remedies by the mouth would be somewhat difficult. A 
sixteenth of a grain of morphine, in combination with one five-hun- 
dredth of a grain of atropine, given hypodermically, would be quite 
safe for a child of eighteen months, and probably would be attended 
with good results. Paregoric or one of the antispasmodics, such as 
musk or castor, may, if the paroxysms are prolonged, be adminis- 
tered by the rectum, although we can scarcely anticipate very prompt 
action when they are given in this way. Capmas suggested pressure 
on the pneumogastric nerves, thus interrupting the efferent nerve cur- 
rent, while Gavoy recommends pressure on the carotid arteries. The 
stimulating action of ammonia, as well as the antispasmodic action of 
chloroform inhalations, has been recommended by a number of ob- 
servers. Unfortunately, during the paroxysm, in most cases, respira- 
tion is completely arrested, which would seem to eliminate any hope 
of success in this direction. The injection into the rectum of a few 
drops of chloroform suspended in milk or water would probably be 
attended by prompter results. The value of emetics, as recommended 
by many observers, is probably confined to those cases of laryngeal 



718 DISEASES OF THE LARYNX. 

spasm which are dependent upon a subglottic laryngitis. If the 
paroxysm is prolonged, and unconsciousness sets in, this is attended 
with general convulsive movements, which are to be attributed now 
probably more to the poisoning of the nerve centres by the arrest of 
oxygenation than to the original affection which precipitated the 
laryngeal spasm. This complication makes it imperative to relieve 
the dyspnoea, either by the introduction of a catheter into the larynx, 
by intubation, or by tracheotomy. In the absence of intubation in- 
struments, tracheotomy would probably be the wiser resort, as in an 
emergency the instrument necessary for the performance of this can 
be improvised, whereas valuable time might be wasted in the futile 
attempt to insert a catheter into the larynx, since this latter is by no 
means a simple manipulation in very young children. 

After the paroxysm subsides, the indications for treatment are to 
prevent as far as possible a recurrence of the attack, by combating 
the disease which has been its cause. The general health must be 
built up by the administration of cod-liver oil with the hypophos- 
phites in connection with the syrup of the iodide of iron; careful 
attention should be paid to the clothing ; the functions of the skin 
should be maintained by the daily use of the cold bath ; and especial 
care is to be taken as regards the diet, which should be of the most 
nutritious character and at the same time easily assimilated. 

Not infrequently a spasm is precipitated by the mere act of taking 
the breast, in which case it becomes necessary to feed the child with 
a spoon. The sleeping-apartments should be properly ventilated, 
and if possible the child taken daily into the open air. The pos- 
sibility of difficult dentition is always to be borne in mind, and the 
gums watched for any source of irritation there. If such is found, 
free scarification should be promptly done. In the same way the 
condition of the bowels is to be carefully attended to and the faeces 
examined for evidence of imperfect digestion. 

Among the remedies suggested to prevent a repetition of the at- 
tack are the bromides, chloral, antipyrin, physostigma, and curari. 

Spasm of the Glottis in Adults. 

The clinical history of spasm of the glottis as occurring in adult 
life presents an entirely different picture from that observed in chil- 
dren, in that it does not ordinarily involve any danger to life. More- 
over, it is in most instances purely reflex in character, and is rarely 
dependent on any morbid lesion of the nerve centres, although we 
must undoubtedly recognize a somewhat abnormal excitability of the 
nervous system as predisposing to the attacks. 



NEUROSES OF THE LARYNX. 719 

Laryngeal spasm may be excited by the entrance of food, drink, 
or other foreign substances into the larynx ; by irritating topical ap- 
plications, as by means of the sponge or probang ; and by the pres- 
ence of movable tumors. It also occurs in connection with tuberculous 
and syphilitic disease of this organ. In the latter cases it is alto- 
gether probable that the spasm is excited by the entrance of solid or 
liquid food into the cavity, the act of deglutition being seriously in- 
terfered with by these affections. In the same way, any affection 
which interferes with this act may be attended with laryngeal spasm, 
such as pharyngeal paralysis, ulcerative processes in the pharynx or 
oesophagus, as well as tumefaction in any portion of the fauces. In 
these cases the laryngeal spasm becomes a grave symptom, accord- 
ing to the extent to which the food is thus diverted into the air 
tract. 

Aside from the above cases, the disease probably is largely con- 
fined to those instances in which the muscular contraction is a reflex 
phenomenon excited by some diseased condition, either in the larynx 
or in some other portion of the upper air tract. 

I am disposed to think that the primary impulse which excites the 
glottic spasm in these cases is in most instances a reflex from the 
laryngeal membrane itself, and that the influence of diseased condi- 
tions of the parts above is largely in producing morbid conditions in 
the laryngeal cavity. 

I do not wish to be understood as taking the ground that all cases 
are purely reflex in character, since, in rare instances, the spasm may 
arise from pressure on the efferent nerves. Thus, it has been known 
to depend upon pressure on the recurrent nerve by a bronchocele, and 
upon irritation of the internal branch of the superior laryngeal nerve, 
caused by a hyperseniic condition of the left pyriform sinus, the outer 
wall of which the nerve traverses. 

It has occurred in connection with tetanic contraction of the mus- 
cles of the upper extremity. The laryngeal crises in the early stages 
of locomotor ataxia are probably spasmodic in character. 

While, therefore, in exceedingly rare instances spasm of the glot- 
tis in adults may be excited by a central lesion or by pressure on the 
efferent nerves, in the large majority of cases we must seek for its 
cause in some reflex excitation having its origin in some portion of 
the air tract. Underlying these, in all instances, there is a peculiar 
nervous excitability, which renders these patients peculiarly subject 
to reflex disturbances. That the disease, therefore, should be more 
common in females than males we can easily understand. On this 
account we should suppose that hysteria might be a cause of the affec- 
tion. This, however, is doubtful. I regard it as an almost invari- 



720 DISEASES OF THE LARYNX. 

able rule that hysteria causes only those affections which can be per- 
fectly simulated by purely voluntary effort. 

Symptomatology. — The only notable feature of the clinical history 
of laryngeal spasm in adults is the fact that it most frequently occurs 
at night, and usually during sleep. The patient is suddenly awakened 
by a paroxysm of dyspnoea, which presents the characteristic features 
of glottic spasm, the labored and crowing inspiration, the struggle 
for breath, and the rapid supervention of cyanosis. The attack lasts 
from five to twenty seconds, and gradually subsides. This may be 
repeated again during the same night, or the attack may not recur 
for a considerable period. There is no periodicity of the disease, as 
is characteristic of the spasm in children. The severity of the parox- 
ysms and their frequency of recurrence are largely dependent upon 
the actively predisposing and exciting causes. 

The nocturnal attacks seem to be somewhat characteristic of those 
cases in which the spasm is a reflex disturbance from some diseased 
condition of the upper air passages. The occurrence of a glottic 
spasm in an adult during waking hours should lead to the suspicion, 
at least, that the disease is dependent upon some morbid condition 
of the nerve centres, or upon pressure on the nerve trunk. When it 
is a crisis of locomotor ataxia, it is more apt to occur in the daytime 
and is usually preceded by a cough. 

Diagnosis. — The clinical history of the case enables us easily to 
establish the diagnosis : the main interest however, is in ascertaining 
the cause of the affection. The elimination of a diseased condition 
of the nerve centres, or pressure on the efferent nerve trunk, suggests 
the reflex character of the seizures. This will be more fully estab- 
lished by discovering some diseased condition of the upper air tract, 
such as atrophic or hypertrophic rhinitis, deflected septum, nasal 
polypi, pharyngeal adenoids, or other obstructive lesions either in 
the nasal passages or in the naso-pharynx. In exceedingly rare in- 
stances laryngeal crises constitute the first symptom of locomotor 
ataxia; in such cases the diagnosis is involved in no little difficulty. 
In most cases, however, of tabes, the laryngeal symptoms, if they ex- 
ist, are accompanied with or preceded by other symptoms. If the 
attacks are the result of pressure upon one of the efferent nerves, this 
will be evidenced in the laryngoscopic image by the impairment of 
motility in the muscles supplied by that nerve. 

The clinical history of bilateral paralysis of the abductors is 
marked by recurrent dyspnceic attacks, which present all the charac- 
teristic symptoms of laryngeal spasm. In these cases, also, the 
laryngoscopic image easily reveals the absence of abductor action in 
the movements of the glottis. 



NEUROSES OF THE LARYNX. 721 

Prognosis. — These attacks involve discomfort and apprehension to 
the patient rather than danger to life. In my experience they are 
quite amenable to treatment, and an improvement in the severity of 
the paroxysms follows promptly upon remedial measures directed to 
the ascertained cause of the affection, when it has been reflex in 
character and dependent upon a diseased condition of the upper air 
tract ; and even in cases in which it is dependent upon organic dis- 
ease of the nerve trunk or the medulla, much can be anticipated from 
remedial measures to overcome the irritability of the mucous mem- 
brane of the laryngeal cavity or passages above, as may be indicated. 

I know of no case of reflex laryngeal spasm in the adult which has 
terminated fatally, yet a number of instances have been reported in 
which tracheotomy became imperative. 

Treatment. — Underlying these cases we must recognize a hyper- 
sensitive condition of the general nervous system. The first indica- 
tion for treatment consists in measures directed to the control of this 
condition. This seems best secured by the administration of bromide 
of potassium or sodium, in from ten to fifteen grain doses three times 
daily. This is to be increased five grains daily until the desired effect 
is produced or bromism occurs. In addition to this, the judicious 
use of the cold bath should be enjoined for its general tonic effect on 
the nervous system, as well as for the purpose of stimulating healthy 
activity of the cutaneous functions. The wearing of thin woollen 
underwear, a certain amount of outdoor life, with physical exercises, 
and such other hygienic measures as may seem indicated, will aid 
much in this direction. 

If atrophic rhinitis exists, the laryngeal spasm is to be attributed 
to the drying up of the mucous membrane of the larynx as the result 
of the deficient secretion of serum in the nasal cavity ; hence the con- 
stant and frequent use of the douche or spray becomes imperative in 
connection with other measures. 

If nasal polypi, deflected septum, pharyngeal adenoids, or other 
obstructive lesions are found, these are to be removed. When the 
disease is dependent upon a morbid condition of the nerve trunk or 
centres, the same indications are present, and afford us a means of 
relieving the severity of the spasm ; for in such cases the severity 
of the glottic spasm may be notably aggravated by any morbid con- 
dition of the mucous membrane of the larynx or the parts above, and 
even when such lesion does not exist in the air passages, the irri- 
tability of the parts may be controlled by soothing local applications, 
such as a two-per-cent solution of cocaine, or perhaps inhalations of 
an infusion of poppies, lupulin, conium, benzoin, or other local seda- 
tives. 

46 



722 DISEASES OF THE LARYNX. 

If the paroxysms are of such a severe type as to imperil the safety 
of the patient, the temporary insertion of a tracheal canula may 
become necessary until the exciting cause of the spasm has been 
removed. 

Laryngeal Inco-okdination. 

In addition to the various neuroses of the larynx already described, 
we have a group of affections in which the essential feature of the dis- 
ease consists in a deficiency in the co-ordinate control or direction of 
the laryngeal muscles. This lack of co-ordination manifests itself in 
the form of a spasmodic contraction of the glottis. In the group of 
diseases under consideration, the spasmodic contraction has entirely 
to do with expiration. 

The affections under this head are: First, chorea of the larynx; 
second, dysphonia spastica ; and third, laryngeal vertigo. 

Chorea of the Larynx. — The prominent feature of this form of 
laryngeal spasm consists in a persistent, noisy, dry cough, which 
closely resembles the bark of a dog. In some cases it occurs every 
two or three minutes, or even more frequently, from the time of wak- 
ing in the morning until the patient falls asleep at night. In other 
cases the intervals are somewhat irregular. The tone of voice is not 
affected, and conversation between the seizures is usually carried on 
easily, although occasionally articulation may be somewhat jerky and 
spasmodic in character. It is preceded by no recovery or drawing in 
of the breath, as is characteristic of an ordinary cough, but comes on 
instantly without regard to respiratory movements, and is completed 
with a single bark in most instances, although in certain cases there 
is a succession of barks of diminished intensity. It occurs usually 
at about the age of puberty, and mostly in females. 

These cases usually tolerate a laryngoscopic examination, and in 
this way the spasmodic character of the glottic contraction is readily 
observed. During the intervals the movements of the larynx are nor- 
mal, vigorous, and well co-ordinated. The occurrence of the paroxysm 
is evidenced by the sudden and sharp closure of the glottis ; the cords 
are driven together, as if by some great external force. After the 
cords have remained in this approximation for one or two seconds, 
they are again separated by a somewhat similar quick movement, 
being drawn well back to the sides of the larynx. This glottic spasm 
seems to excite a sudden expulsive effort on the part of the expiratory 
muscles of the thorax, by which the glottis is forcibly opened after 
the closure has persisted for one or two seconds, and this is accom- 
panied by the characteristic loud bark peculiar to the paroxysm. 

The choreic character of the disease is still further manifested by 



NEUROSES OF THE LARYNX. 723 

the fact that we occasionally meet with similar choreic movements in 
other portions of the body, although these are absent in the majority 
of cases. 

Dysphonia Spastica. — This affection, which is designated both as 
aphonia and dysphonia spastica, differs from laryngeal chorea, in the 
fact that the glottic spasm occurs only during an attempt at pho- 
nation. The disease is practically one of adult life, and occurs more 
frequently in females than males. 

The onset of the attack is marked by impairment or complete loss 
of voice. This is soon followed by the development of the peculiar 
spasmodic character of the disease, under the influence of which, 
whenever the patient attempts to phonate, the cords are brought into 
such absolute apposition that the glottis is completely closed, thus 
preventing the exit of air for phonative purposes. This closure in all 
cases involves the ligamentous glottis, but occasionally the cartilag- 
inous glottis may remain slightly patulous. In some instances the 
closure of the glottis is not sufficient to completely prevent the exit 
of air, but in these cases the tension is such that the voice is thrown 
into the falsetto register. In many cases the disease seems to develop 
in individuals from over-use of the voice, and the spasm is precipitated 
by an attempt to bring into use the overtaxed and wearied muscles. 

The spasm appears to continue so long as the impulse from the 
phonatory centres is sent along the efferent nerves, and ceases in- 
stantly upon the cessation of the conscious effort to talk. When the 
attempt at phonation is persisted in cyanosis may occur. If a laryn- 
goscopy examination is made, the movements of the larynx will be 
found normal and vigorous iu every way. On attempts at phonation 
the cords will be adducted as in health. Immediately upon approxi- 
mation, however, a spasmodic contraction ensues. So close is this 
approximation that one cord may overlap the other, while one of the 
arytenoid cartilages falls in front of its fellow. Immediately upon 
the abandonment of the attempt at phonation, the normal respiratory 
movements of the larynx are seen to take place. 

Laryngeal Vertigo. —This is a curious form of larj^ngeal spasm 
which is followed immediately by vertigo and loss of consciousness. 
A patient in apparently perfect health is suddenly seized with a sense 
of tickling or irritation of the larynx, which produces a slight 
cough. This is immediately followed by an obscurity of vision, 
dizziness, and he falls to the floor in a state of complete uncon- 
sciousness. This lasts for a few seconds, when consciousness returns. 
The attack entails no sense of either physical or intellectual weak- 
ness or discomfort; in other words, the recovery is absolutely com- 
plete. Ordinarily, there are no premonitory symptoms. 



724 DISEASES OF THE LARYNX. 

The attacks recur at irregular intervals varying from a few days 
to weeks and even months, and usually come on without assignable 
cause, although in some instances they seem to have been precipitated 
by nervous excitement, weariness, or over-exertion. In mild attacks 
the seizure may pass away with the occurrence of simple dizziness 
and obscurity of vision, and before unconsciousness has occurred. 
Muscular twitchings during the unconscious state of the attack have 
been noted in a few cases. 

Immediately preceding the attack, the patient draws a full inspi- 
ration, when, the glottis being closed by spasmodic contraction, expi- 
ration is arrested. The futile attempt to force the air through the 
closed glottis results in increased intrathoracic pressure, interruption 
of the circulation, and marked diminution of the vigor of the cardiac 
contractions. The ultimate result of these conditions is a disturbance 
of the circulation of blood, both about the motor centres of the larynx 
in the medulla, and also in the psychic centres of the cranial cavity. 
These phenomena seem to occur usually in individuals of a neurotic 
habit. 

In most instances the laryngeal cavity presents no evidence of 
local morbid lesion, although in some cases observed the attacks 
seemed to be dependent upon a catarrhal laryngitis. 

The disease is a somewhat rare one. 

It is easily recognized by the clinical symptoms, and the diagnosis 
is not dependent in any way upon laryngoscopic examination. 

Prognosis. — None of these affections involve any dangerous tenden- 
cies, so far as life is concerned. In chorea and dysphonia spastica 
the disease is an essentially chronic one, and often resists for a long 
time all methods of treatment. In laryngeal vertigo, on the other 
hand, the prognosis seems to be favorable as regards treatment, in 
that all cases so far reported seem to have been permanently cured 
after a comparatively short course of medication. 

Treatment. — All these cases, being of neurotic origin, demand that 
our first efforts should be directed toward the correction of the sys- 
temic condition. For this purpose general tonics, such as barks and 
iron, cod-liver oil and hypophosphites, may be used. Strychnine is 
usually contraindicated. The preparations of zinc, belladonna, and 
phosphorus have been extensively used, but without any notably good 
results. The stimulating and tonic effect upon the general nervous 
system of cold water, in the form of either the sponge, shower, or tub 
bath, is so well known that its value in these cases cannot be ques- 
tioned. Its best effect is in producing a certain amount of shock 
upon the system, and this of course is secured most promptly in the 
use either of the shower or douche. The action of the bath is to be 



NEUROSES OF THE LARYNX. 725 

closely watched, and its use can only be continued, of course, in those 
cases in which a proper reaction follows the immersion. Among 
general hygienic measures which are to be considered are the proper 
regulation of the clothing, exercise, fresh air, the regulation of the 
diet, and the proper ventilation of living and sleeping apartments. 

Too much importance cannot be attached in these cases to the cor- 
rection of such morbid conditions as may be found in the upper air 
tract. While in probably all these cases the neurotic habit is the 
active predisposing cause of the attack, I am confident that the out- 
break is in many instances directed to the larynx by some diseased 
condition of either the nasal passages or the faucial region. 

There are certain special points to which attention should be 
called in connection with the separate affections. 

Chorea of the Larynx. — The first indication for treatment in 
this affection is in the correction of any morbid condition which may 
be found in any portion of the upper air tract. Even when there is no 
local lesion in the larynx or air tract, soothing applications undoubt- 
edly afford temporary relief. For this purpose we may use inhala- 
tions of conium, hyoscyamus, lupulin, papaver, or hot steam, or per- 
haps resort to local applications of solution of morphine or cocaine. 

The literature of the subject seems to indicate that in a majority 
of cases the remedies which have shown the best results, in addition 
to general hygienic measures, have been bromide of potassium given 
in full doses and the faradic current, although Knight recommends 
the use of the continuous current. 

Dysphonia Spastic a. — In this form of inco-ordination the 
indications for treatment are practically those already enumerated in 
connection with chorea of the larynx, with the addition of such com- 
plete rest of the organ as can be enforced, together with the use of 
the constant current, applications of which should be made daily until 
a cure is effected. 

Laryngeal Vertigo. — The neurotic element is especially 
prominent in this form of laryngeal inco-ordination ; and in addition 
to the general measures already referred to, the patient should be 
brought thoroughly under the influence of the bromides. 

If, however, any morbid condition of the upper air tract is found, 
the bromides will fail of their beneficial action until this is corrected 
by proper treatment. 



CHAPTER LXXXIX. 

FOREIGN BODIES IN THE AIR PASSAGES. 

The entrance of a foreign body into the larynx or air passages 
below during the acts of mastication, deglutition, or inspiration or 
otherwise gives rise to more or less grave symptoms, according to the 
size, character, and location of the body. 

Etiology. — The articles which may thus make their way into the 
breathing-tract cannot well be enumerated, comprising as they do 
almost every known substance, such as pins, coins, particles of food, 
pebble-stones, natural and artificial teeth, peas, beans, fragments of 
bone, buttons, nutshells, lumbricoides, hydatids, etc. 

In the large majority of instances the accident occurs during the 
act of inspiration, the individual drawing a heedless or perhaps in- 
voluntary breath while food or other solid matters are in the mouth. 
Children occasionally fall asleep with foreign bodies in the mouth, 
such as coins, buttons, toys, etc., which are thus very liable to make 
their way into the air passages. 

False teeth also occasionally become dislodged during sleeping- 
hours and fall into the air passages. As a rule, however, they are 
arrested in the pharynx. 

The pharynx is the seat of a very high degree both of motor and 
sensory innervation, and in the very large majority of instances 
when a foreign body reaches the pharynx it is immediately expelled 
by the prompt reflex action which its presence excites. When this 
sensibility is diminished, as during sleeping-hours, we can easily 
understand how conditions are established which favor the passage of 
foreign bodies beyond this region, and into the larynx and trachea. 
The pharyngeal insensibility of anesthesia is even still more marked 
than that of sleep, which will in part explain the accidents which oc- 
cur in this state. Some cases have been reported in which the foreign 
body has come from below, as, for instance, that of a diseased bron- 
chial gland which has made its way into the bronchial tube by an ul- 
cerative process and passed up into the larynx ; or the occlusion of 
the larynx by cheesy matter from an ulcerating bronchial gland. 

Symptomatology. — In very rare instances a foreign body may 



FOREIGN BODIES IN THE AIR PASSAGES. 727 

make its way into the air passages without the individual being cog- 
nizant of the accident, the symptoms being delayed until local in- 
flammatory changes set in, giving rise to cough, pain, dyspnoea, etc. 
In the very large majority of cases, however, the occurrence of this 
accident makes itself known by the immediate development of symp- 
toms of a somewhat distressing character. The patient is seized with 
a sudden choking or gasping for breath, with a feeling of impending 
suffocation. The dyspnoea is usually of an inspiratory character, 
the presence of the foreign body setting up a spasm of the larynx. 
The alarm and anxiety of the patient is shown by his restless move- 
ments ; he rushes to the window or door in a hopeless effort to obtain 
air ; the eyes protrude and the face soon becomes livid from defective 
oxygenation. These symptoms may continue until death ensues, or 
at the end of a few minutes they may gradually subside and fairly 
normal respiration set in. The subsequent history of the case is 
marked by recurrent attacks of a dyspnceic character, apparently de- 
pendent somewhat on the position and movements of the individual, 
and perhaps on the character and location of the foreign body. If 
the substance be smooth and rounded, and possess no especially ir- 
ritating properties, it may remain in the air passages for years with- 
out giving rise to notable local changes. 

As a rule, the impact of the foreign body upon the delicate struc- 
tures of the air tract gives rise to inflammatory and ulcerative proc- 
esses. Among the direct results of its presence, therefore, we may 
enumerate, according to its location, laryngitis, oedema of the larynx, 
abscess of the larynx, inflammation or ulceration of the trachea or 
bronchi, emphysema, pneumonia, pleurisy, abscess of the lungs, and 
necrosis of the cartilages, either of the larynx or trachea. As the 
result of these conditions the continued presence of the foreign body 
thus gives rise, if in the larynx, to hoarseness, loss of voice, and re- 
current or permanent laryngeal spasm, with cough and expectoration.. 
If the foreign body is located in the trachea or bronchi, we have per- 
sistent cough, with more or less muco-purulent expectoration, which 
is perhaps tinged with blood, together with dyspnoea. The long-con- 
tinued presence of the foreign body, with its resultant ulcerative ac- 
tion, gives rise to marasmic symptoms, as progressive loss of flesh, 
febrile disturbance of a hectic nature, night sweats, loss of appetite, 
and other symptoms which so closely resemble an attack of pulmon- 
ary phthisis as to lead not infrequently to a mistaken diagnosis. If 
pneumonia, pleurisy, or other secondary morbid process set in, 
it gives rise to symptoms characteristic of such affection. The bron- 
chitis which occurs is peculiar, in that it assumes somewhat of an 
intermittent character. In addition to the above symptoms, pain is 



728 DISEASES OF THE LARYNX. 

almost constantly present in these cases, and it usually locates itself 
in such a way as to indicate clearly the position which the foreign 
body has assumed in the air passages. 

Hemorrhage is not ordinarily a prominent symptom, yet in a 
case which came under my own observation this was the prominent 
feature of the affection. 

Diagnosis. — The history of the case ordinarily will establish the 
character of the accident; in the absence of any such history, we have 
no means of definitely determining the existence of a foreign body in 
the breathing-passages, except in those cases in which its lodgement 
is in the larynx or trachea, when it can be brought under ocular in- 
spection by the use of the laryngoscope. Digital exploration, of 
course, is of value only when the object is in the larynx. 

The main interest in this connection has to do with the location of 
a foreign body which has passed into the bronchi. In most instances 
the right bronchus is invaded, on account of its anatomical position. 
The subjective symptoms, especially that of pain, as before noticed, 
will of course aid us in locating the object. Also auscultation may 
detect its immediate location by the peculiar harsh or sonorous rale 
which results from the air passing in respiration, provided the tube 
is not completely occluded. If the latter condition exists, we are 
compelled to depend largely on the absence of the respiratory mur- 
mur in that portion of the lung supplied by the occluded bronchus. 
Cohen makes the note that obstruction of the left bronchus causes an 
absence of respiratory murmur over the entire left lung, while occlu- 
sion of the right bronchus usually produces absence of the respiratory 
murmur over the lower lobe alone of that side ; the division of that 
bronchus taking place much nearer the bifurcation, and foreign bodies 
rarely lodging above the point of vision. 

In the case of a foreign body in one of the bronchi giving rise to 
symptoms closely resembling pulmonary phthisis, and without a pre- 
vious history of its entering the passages, the question of diagnosis 
becomes one of no little difficulty. A unilateral bronchitis with re- 
current exacerbations and muco-purulent expectoration tinged with 
blood, accompanied by progressive loss of flesh and hectic fever, 
ought certainly to suggest the possible presence of a foreign body as 
the cause of the symptoms, especially if an examination of the sputa 
fails to detect the tubercle bacillus. 

Prognosis. — The entrance of a foreign body into the air passages 
is to be regarded as an accident of an exceedingly grave character, 
and presents a very serious menace to life, either from the immediate 
symptoms which arise, or from the secondary morbid processes which 
are liable to develop in the air passages. 



FOREIGN BODIES IN THE AIR PASSAGES. 729 

Immediately upon the entrance of a foreign body into the air 
tract, nature endeavors to expel it by the instant cough and other re- 
flex movements which are set in play. In the very large majority of 
instances these are successful. 

Combining the statistics of Gross, Durham, and Weist, we have 
1,674 cases. An analysis of these shows that without operation 
death occurred in 28.6 per cent, and in 25 per cent after operation. 
Of course the idea is not intended to be conveyed that the results in 
the operative and non-operative cases are to be compared, for, as 
we have seen, a large percentage of the patients in non-operative 
cases died before relief could be afforded. 

There seems to be no limit to the time in which voluntary expul- 
sion may take place, as it has been known to occur at all times from 
one day to sixty years. There can be no question as to the propriety 
of extracting these substances at the earliest period possible, however, 
whether with or without operative procedure; and, furthermore, even 
after the expulsion of the body the danger to life has not been re- 
moved. 

Treatment. — Our first effort in any given case should be directed 
toward ascertaining the character and location of the foreign body 
with which we have to deal. 

After the acute manifestations have subsided, such as choking, 
spasm, etc. , as they usually do in the course of a few minutes, the 
gravity of the situation can be determined by the symptoms which 
remain. If the dyspnoea is of such a character as to threaten suffo- 
cation, of course immediate resort should be had to operative inter- 
ference. If, however, the symptoms are not urgent, an effort should 
be made to secure the expulsion of the foreign body through the 
natural passages. 

The administration of sternutatories and emetics is of doubtful 
value. Much more can be hoped for by a well-directed and intelli- 
gent voluntary expiratory effort. The patient should be directed to 
take a slow, deliberate, and full inspiration, after which the air is to 
be forced out violently, in the hope of dislodging the substance. 
This manipulation is aided by violent blows upon the chest at the 
time of the expulsive effort. An additional aid is also secured by 
inverting the body, in the manner so successfully resorted to by Pad- 
ley for the removal of a coin from the windpipe. The patient sat with 
his knees fixed over the elevated end of a strong bench, when upon 
lying down on his back the coin fell into the mouth. The advantage 
of the supine position over the prone is that, in case of the body 
lodging against the rima glottidis, the spasm which would ensue is 
avoided by the quick recovery of the erect position. Most writers 



730 DISEASES OF THE LARYNX. 

seem to think that there is a certain amount of danger attendant upon 
the attempt to secure the expulsion of a foreign body by position, 
owing to the risk of its becoming impacted in the chink of the glottis. 
On this ground Weist is of the opinion that it should never be prac- 
tised without previously opening the air passages. I am disposed to 
think the danger greatly overestimated, and it certainly is very 
largely eliminated by Padley's ingenious plan, with reference to 
smooth, round bodies. If we have to do, however, with bodies of ir- 
regular shape and sharp edges, this danger must be kept in view, 
whatever manipulations are resorted to. 

In case of failure of the above methods, our subsequent resort is 
to the use of forceps and other instruments for extraction in those in- 
stances in which the foreign body lies in the larynx. This is accom- 
plished either with the aid of the laryngoscopic mirror or the index 




Fig. 155.— Cusco's Laryngeal Forceps. 

finger inserted into the larynx. In most cases probably the Cusco 
forceps (see Fig. 155), on account of the firmness of grasp and freedom 
of play of the blades, will answer better purposes. Figs. 156 and 157 
illustrate an interesting case reported by Grazzi, in which a horizon- 
tal grasp was necessary for the extraction of a coin from the laryngeal 
ventricle. Gruening makes the suggestion that, in a case in which 
there is danger of the body becoming dislodged in the larynx and 
dropping into the trachea during the manipulation, preliminary trache- 
otomy should be performed. In the case of jagged bodies, the danger 
of injury to the soft parts, by which permanent vocal impairment may 
result, is always to be borne in mind, and it occasionally may seem 
wiser to crush such substances as nutshells, pieces of bone, etc, 
rather than to lacerate the tissues in their extraction. In case the 
impaction is the result of localized swelling, of course it may seem 
wiser to await the subsidence of this. Brandeis extracted a thread 
from the larynx by means of a brush dipped in mucilage. 



FOREIGN BODIES IN THE AIR PASSAGES. 



731 



These operations through the natural passages in adults are very 
easily accomplished without anaesthesia. With children, however, it 
will become necessary in most instances to administer an anaesthetic, 
to secure not only proper control of the patient but also tolerance of 
the passages. Laryngoscopy in young children during anaesthesia 
is by no means an easy matter in all cases. In such a case the index 
finger in the larynx not only serves to explore the cavity, but also 
acts as a guide to the forceps. 

In case of failure of the above methods tracheotomy becomes 
necessary to relieve the dyspnoea due to the impaction of a foreign 
body in the larynx ; to secure access to such body ; to secure better 
access to the lower air passages, or in rare instances as a precaution- 
ary measure in the manner already alluded to. As a rule, the indi- 
cations are for a low tracheotomy, although it may be occasionally 
necessary, in order to obtain access to a substance in the laryngeal 





Fig. 



156.— Coin in Laryngeal Ventricle 
(Grazzi). 



Fig. 157.— Coin in Grasp of Forceps, showing 
Method of Removal employed in Grazzi's 
Case. 

cavity, to perform high tracheotomy, or a crico-thyrotomy, or even 
a thyrotomy ; even in those cases in which it becomes necessary to 
open directly into the larynx, it is probably wiser first to perform the 
low tracheotomy. 

After the performance of tracheotomy, the foreign body may be 
extracted by manipulation through the mouth, or instruments may 
be inserted through the tracheal opening and the object forced into 
the oral cavity. When the operation is done for a foreign body in 
the trachea or bronchi, it is not infrequently expelled immediately 
upon opening the trachea, or it may be forced up so near to the 
tracheal opening as to enable the surgeon to seize it with the forceps. 

Failing this, it may become necessary to resort to the supine posi- 
tion, or succussion of the body, in order to detach it from the parts 
below and enable it to be forced up near to the tracheal opening. In 
case of failure of tracheotomy to bring the object within reach by the 
simpler manipulations, it is to be sought for by probes and forceps 
passed directly down into the trachea. 

In order to obtain free access to the tracheal cavity for subsequent 



732 



DISEASES OF THE LARYNX. 



manipulation, the edges of the incision should be held as widely 
apart as possible by proper instruments, such as Labord's dilator or 
Minor's retractor (see Fig. 158), or, better still, threads should be in- 
serted into the tracheal rings and the parts held open in this man- 
ner. In a case reported by Wyeth, the edge of the tracheal wound 
was stitched to the integument, thus securing a permanent opening 
for subsequent exploration, the first having failed. 

The exploration of the trachea may be done either with the finger 




Z7^ 
Fig. 158. — Minor's Tracheal Retractor. 

or with a long slender probe bent at right angles, although a better 
process probably consists in using the forceps for exploratory pur- 
poses. Gross used a long, flexible forceps constructed of German sil- 
ver, similar to those shown in Fig. 159. Cohen has devised a pair of 
shouldered forceps for this purpose. Jacobson reports the successful 
use of Stoerk's laryngeal-tube forceps, a most admirable device, in 
that the tube, being constructed of German silver, can be easily bent 
to a proper angle. Seiler's tube forceps (see Fig. 160) also serves an 




Fig. 159.— Gross 1 Tracheal Forceps. 

excellent purpose. If the foreign body be a small, jagged object, 
such as a nutshell or piece of bone, it will often be quite sufficient 
simply to disengage it from the soft parts. This can be done by a 
slender silver probe, with the end bent into the form of a hook. 
After dislodgement, it is usually easily expelled. 

Of course, after the trachea is opened, still further inspection may 
be made by means of reflected light, a small mirror being inserted 
into the wound. 



FOREIGN BODIES IN THE AIR PASSAGES. 733 

The insertion of the finger into the trachea for the purposes of 
locating: or even dislodging a foreign body is always available, and 
the bifurcation can easily be reached in this manner. 

The strength and endurance of the patient should never be taxed 
by too prolonged efforts at exploration and extraction of a foreign 
body immediately following the performance of tracheotomy, for 
the procedure can be postponed to the next day, or even for a week, 
without involving any additional danger to the patient. Moreover, 
after the windpipe is opened, dislodgement and voluntary expulsion 
can be anticipated at some future time. In view of this, it is scarcely 
necessary to add that the tracheal opening should not be occluded by 
the insertion of a tube, as in such a case the expulsion of a foreign 
body would thus be interfered with. In case it becomes necessary to 
postpone the attempt to a later period, the wisest procedure would be 





Fig. 160.— Seiler's Tube Forceps. 

to stitch the edge of the tracheal wound to the integument, as was 
done by Wyeth. 

Tracheotomy and subsequent manipulations having been unsuc- 
cessful, an expectant plan of treatment, for a while at least, is 
the wisest procedure in those cases in which the presence' of a foreign 
body in the bronchus gives rise to no immediately dangerous symp- 
toms. If, however, further interference becomes imperative, in 
such a case only is the resort to the operation recommended by 
Nesiloff, for exposing the bronchi, warranted. The patient being 
placed on his abdomen, a vertical incision is made three inches to the 
left of the median line and extending from the third to the sixth dor- 
sal vertebra. From each extremity of the vertical incision two hori- 
zontal incisions are carried toward the vertebrae. The flap is then 
raised, uncovering the third, fourth, fifth, and sixth ribs, which are 
then cut through, upon which subperiosteal excision is made. The 
pleura is then pushed forward, and the bronchus searched for at the 
bottom of the wound. McBurney suggests that, considering the angle 
at which the left bronchus passes into the trachea, an incision might 
be made into the right side of the trachea, in such a locality as will 
afford direct access to this tube. 



CHAPTER XC. 

FEACTUEE OF THE LAEYNX. 

This is an accident which is usually the consequence of a fall, a 
direct blow, or pressure on the organ, and may result in the fracture 
of a single cartilage, or two or more may be involved in the injury. 
It usually gives rise to symptoms of rather serious import, and is 
generally regarded as an exceedingly rare occurrence. 

Etiology. — The direct cause of the accident may be either a fall 
from a height upon some projecting object, or it may result from a 
flying missile. In a number of instances the injury has been inflicted 
by a bullet. It also occurs in the act of garrotting or hanging, and 
during personal encounters either from a blow of the fist or from 
compression in being choked by an antagonist. Muscular action 
during coughing has caused the fracture. 

It is generally stated that the ossification which the cartilages 
undergo with advancing years renders one more liable to this injury ; 
yet a large majority of the cases which have been reported have oc- 
curred during the third, fourth, and fifth decades of life, while seven 
instances have been observed in which the accident occurred in the 
first decade. 

Symptomatology. — The first result of the accident usually is an 
external deformity, which consists in a sinking in of the laryngeal 
prominence in the neck, unless the injury is the result of lateral com- 
pression, in which case an undue prominence is liable to occur. The 
injury to the soft parts gives rise to more or less extensive external 
tumefaction, which may be the direct result of the blow, or it 
may be due to any emphysematous infiltration of the tissues where 
the fracture extends completely through the lining membrane of the 
larynx. The internal injury necessarily causes rupture of the blood- 
vessels, and hence dyspnoea very early becomes a prominent symp- 
tom, either from the escape of blood into the air passages or into the 
submucous tissues. The dyspnceic symptoms may set in immediate- 
ly upon the occurrence of the accident, or they may be delayed for 
some days. The voice, of course, is either impaired or completely 
lost. Cough is usually present, with pain on deglutition. The es- 



FRACTURE OF THE LARYNX. 735 

sential and almost pathognomonic symptoms are, however, the dysp- 
noea and bloody sputa. 

As regards the cartilages involved, Durham's report shows fracture 
of the thyroid alone in 24 cases, of the cricoid in 11, of the thyroid 
and cricoid in 9, of the thyroid, cricoid, and trachea in 2, of the 
cricoid and trachea in 2, of the thyroid and hyoid in 4, of the thyroid, 
cricoid, and hyoid in 2, of the cricoid, trachea, and hyoid in 1, while 
in 7 theexact location is not given. 

The accident may result in a simple linear fracture, or the fracture 
may be comminuted and even compound. 

Diagnosis. — The clinical history of the case, together with the 
evidence of external injury, the flattening of the laryngeal prominence, 
with the bloody sputa and dyspnoea, if present, constitute symptoms 
sufficiently characteristic. In addition to these, palpation of the parts 
enables one to recognize the deformity and the presence of emphysema 
by its peculiar crackling sound, and also in most cases the crepita- 
tion between the fragments. Laryngoscopic examination will show 
the distortion of the laryngeal cavity, with submucous extravasation, 
or the escape of blood into the air passages, as the case may be. 

Prognosis.— The accident is to be regarded as one of no little 
gravity ; this varies, however, somewhat according to the special car- 
tilages involved. Thus, if the thyroid cartilage alone is the seat of 
fracture, the danger is much diminished ; while cases in which the 
cricoid ring is crushed are generally regarded as almost invariably 
fatal. We find that in 62 cases reported by Durham, there were 12 
recoveries; in 6 of these the thyroid alone was involved, in 2 the 
thyroid and hyoid, and in 4 the seat of injury was not recorded. 

The injury gives rise to immediate laryngeal obstruction, while 
subsequently, if the patient survives, a somewhat prolonged suppu- 
rative process is liable to ensue. Furthermore, the emphysema may 
extend into the perilaryngeal or peritracheal tissues, or even as far 
down as the mediastinum. The fatal termination, therefore, may re- 
sult either from suffocation or from the subsequent development of 
pneumonia, pleurisy, pulmonary oedema, mediastinal abscess, septi- 
caemia, or some other complicating disorder. 

Treatment. — Efforts should be made to control such inflammatory 
action as may develop, by means of counter-irritants, leeching, and 
cold dressings. If there is any displacement of the parts, they 
should be restored as far as possible by external manipulation, and 
held in place by light strips of adhesive plaster, while at the same 
time all movement in the larynx is controlled as far as practicable by 
not only the avoidance of the use of the voice, but of any attempt at 
deglutition, food being administered by the rectum if necessary, or 



736 DISEASES OF THE LARYNX. 

by means of a tube. The case must be watched with the greatest 
care, and preparations made for the performance of tracheotomy as 
soon as any evidence of laryngeal stenosis manifests itself. The 
canula should be inserted as low down as possible, for we are by no 
means able in all cases to determine how far the traumatism has 
extended. 

Attention should then be directed toward the restoration of the 
parts to their normal position and the preservation of laryngeal func- 
tion. If the tracheal canula is in position, this will be accomplished 
either by the manipulation of a probe in the larynx or by the inser- 
tion of bougies, or possibly thyrotomy may be demanded to obtain 
access to the larynx for the restoration of the parts or for the removal 
of projecting fragments. 

If the patient survive the injury, the subsequent cicatrization may 
result in such a narrowing of the larynx as to render the permanent 
wearing of the tube a necessity. In such an event, the best results 
in treatment will probably be obtained by resort to intubation, not 
with the ordinary intubation tube, but with a conical instrument, by 
which dilatation may be accomplished. 



CHAPTER XCL 

PEOLAPSE OF THE LARYNGEAL VENTEICLES. 

The possibility of prolapse of the lary ngeal ventricles is placed 
beyond question by a number of well-authenticated cases. Tubercu- 
losis existed in eight of the cases reported, and syphilis in two. 

The only direct cause for the accident seems to be the violence to 
which the tissues are subjected during the act of coughing, when 
there exists at the same time a relaxed condition of the mucous mem- 
brane. It is possible that this may result in the severing of the at- 
tachments of the thyro-arytenoid muscle, and with it the attachment 
of the mucous membrane lining the ventricle. 

The symptoms are either impairment or complete loss of voice, 
?tnd, when the tumefaction has attained sufficient proportions, a 
moderate amount of dyspnoea is present. The diagnosis, at best, 
must be somewhat difficult. The tumor presents as a rounded or 
somewhat spindle-shaped mass, smooth in contour, of a pale pinkish 
tinge, or slightly injected; it lies directly upon the vocal cord, 
and seems to emerge from the ventricular fissure. It is soft in con- 
sistency, and easily indented by means of a probe. It should not be 
confused with a fibroid, which is a hard, dense tumor, irregularly 
nodulated and not pedunculated; moreover, fibroid tumors never 
arise from the laryngeal ventricle. The long clinical history of the 
disease, together with the absence of ulceration or glandular involve- 
ment, should be considered in the elimination of a possible malignant 
origin of the growth. 

A certain amount of good can be accomplished by means of local as- 
tringents in reducing the size of the tumefaction. Successful replace- 
ment cannot be hoped for. Complete restoration of the vocal function 
can be anticipated only by treating the affection as a neoplasm and re- 
moving it. This may be done either by means of the snare manipu- 
lated through the natural passages, or, failing this, by performing 
thyrotomy. Jellcnfy, regarding the affection as a sort of incarce^ 
rated hernia, endeavored in several of his cases to shut off the cir- 
culation by a series of superficial incisions over its contour, thus 
successfully reducing the prolapse. 
47 



CHAPTER XCII. 

BENIGN TUMOKS OF THE LAEYNX. 

The important place which the consideration of benign tumors of 
the larynx has occupied in the literature of throat diseases during the 
past thirty years and more would carry the suggestion that this form 
of disease possesses a clinical significance of unusual importance, and 
that the development of a laryngeal growth is to be regarded as a 
matter of no little gravity. 

I am disposed, however, to think that its importance is somewhat 
overestimated, as I do not regard the existence of a benign tumor in 
the larynx as involving any especial danger to life. Yet I do not wish 
to be understood as in any way underestimating the importance of 
benign growths and their treatment. 

The development, progress, and symptoms of the various benign 
neoplasms of the larynx are practically identical, and hence it will be 
found convenient to discuss them collectively, differentiating only 
when it seems necessary, as in the pathology and diagnosis. 

The varieties of these tumors are: Papilhmata, fibromata, cysto- 
mata, myxomata, adenomata, Upomata, angiomata, enchondromata, 
and mixed tumors. 

Etiology. — It is exceedingly difficult to assign a definite cause 
for the development of a laryngeal neoplasm. It is usually stated 
that a hyperemia of the mucous membrane, or perhaps a catarrhal 
inflammation, is the most active cause of the affection, and yet un- 
doubtedly a large majority of the cases develop in a previously 
healthy larynx; certainly, in most of the cases which have come 
under my own observation not only was it difficult to discover any ex- 
isting inflammatory affection to account for the disease, but the pres- 
ence of the growth itself failed to excite any morbid process in the 
surrounding tissues. Traumatism, in the form of laryngeal strain, 
or overexertion of the voice, is undoubtedly to be regarded as a not 
infrequent cause of the disease. Exposure to cold, the inhalation of 
irritating vapors, eruptive fevers, etc., constitute active causes in 
some cases. In several instances warty growths have occurred in the 
larynx simultaneously with their appearance in other parts of the 
bodv. 



BENIGN TUMORS OF THE LARYNX. 739 

Syphilis and tuberculosis are by many regarded as the cause of 
laryngeal growths. These often appear as wart-like excrescences, 
which develop usually on the anterior face of the arytenoid commis- 
sure, especially in tuberculous disease. These vegetations should be 
regarded as local manifestations of the constitutional taint rather 
than as distinct tumors. The disease belongs essentially to adult 
life. The great preponderance of cases occurring in males would 
seem to lend weight to the view that catarrhal inflammation is an 
active cause of the affection. 

While growths in early life, especially of the papillomatous 
variety, are not rare, the statement that they are most frequent in 
early infancy is probably incorrect. 

While the congenital origin of the disease is probably frequent, 
yet a number of well-authenticated cases have been observed. 

Symptomatology. — A benign tumor in the larynx makes its pres- 
ence known mainly by its interference with the function of phona- 
tion, and in rarer instances with that of respiration. It would seem, 
however, that a sessile growth in the aryepiglottic folds or epiglottis, 
or even in the ventricular bands, might develop without producing 
any notable impairment in the pitch or quality of the voice. While 
the ordinary conversational voice is not impaired, its volume and 
strength is affected, according to the size of the growth; and even 
though this may be very small, the voice is liable to be weak and 
tires easily, even after moderate usage, whether the tumor be located 
upon the cord or in other portions of the larynx. 

The morbid condition, being confined to the larynx, very rarely 
gives rise to reflex disturbances ; therefore the presence of a growth, 
even though it may be attended with a certain amount of hyperemia 
of the mucous membrane, rarely gives rise to cough. 

Interference with respiration, of course, is directly dependent 
upon the size of the growth, and to a certain extent upon its location 
as encroaching upon the chink of the glottis. 

Spasmodic contraction of the muscles of the larynx occasionally 
occurs from the presence of the growth ; this is especially true in 
young children. Pedunculated growths, whose favorite point of 
origin is near the anterior commissure of the vocal cords, will often- 
times give rise to dyspnoea when they fall below the glottis, which is 
completely relieved when they are blown out, as it were, upon the 
superior surface of the cords. 

A catarrhal laryngitis, excited by the presence of a growth, 
rare in adults, is very common in young children As the result 
of this condition, nocturnal exacerbations of dyspnoea are fre- 
quent. 



740 DISEASES OF THE LARYNX. 

Hemorrhage is an exceedingly rare symptom, although when a 
papilloma is located near the vocal cords, and is subjected to attrition 
in the movements of the parts, its surface may become eroded, and 
the sputa be tinged with blood. 

Pain is rarely, if ever, present, and only when the growth has 
attained a considerable size. 

Fauvel reports in nearly a fourth of his cases a certain perversion 
of the sense of taste with excessive secretion of saliva. 

Pathology. — The pathological characteristics of laryngeal neo- 
plasms will necessarily be considered under separate heads. 

Papillomata. — This form of neoplasm occurs more frequently than 
all other varities together. This is the form of growth to which Vir- 
chow applies the term "pachydermia verrucosa," in contradistinction 
to "pachydermia diffusa." 

The essential morbid changes which characterize the twq forms of 
the disease commence in the papillae of the mucosa, giving rise to 
certain hypertrophic changes, which in the diffuse form of the dis- 
ease expend themselves largely in the deeper tissues, without exteod- 
ing to the superficial layers of the mucous membrane or epithelial 
structures. In the former variety, viz., the pachydermia verrucosa 
or papillomata, the changes which take place not only involve the 
papillae of the mucosa, but also extend to the epithelial structures on 
the surface. The activity of the process here, however, is found in 
the epithelium rather than in the mucosa. The process limits itself 
to a circumscribed area and consists of a localized efflorescence or 
proliferation of epithelial cells, which pile themselves up in such a 
manner as to produce practically a wart-like growth on the surface, 
instead of losing their vitality and undergoing desquamation as is 
usually the case. 

The surface of a papillomatous growth is marked by numberless 
small rounded projections, each one of which probably marks the 
site of an individual papilla in the normal mucous membrane. If a 
longitudinal section be made through one of these papillary projec- 
tions, there will be found occupying its centre the elongated papilla 
containing the original vascular loop, supported by loose connective 
tissue, and the whole surrounded by from fifteen to twenty layers of 
epithelial cells. 

As a rule, a papilloma is sessile in character, though occasionally 
pedunculated. It may occur singly or in groups, and varies in size 
from a millet-seed to a growth more or less completely filling the 
supraglottic laryngeal cavity. 

Thus, in adult life their growth is somewhat slow, while in child- 
hood they develop with considerable rapidity. Their increase in 



BENIGN TUMORS OF THE LARYNX. 741 

bulk is at the same time accompanied with a broadening of their base, 
by the involvement of neighboring papillae. 

As a rule", all forms of benign tumors confine themselves to the 
supraglottic portion of the larynx in adult life, although in children 
they occasionally extend below the cords. 

Fibromata. — This form of growth occurs next in frequency to the 
papillomata, and constitutes from eight to ten per cent of all cases 
observed. It belongs essentially to adult life. 

In composition it does not differ essentially from similar growths 
met with in other portions of the body. It is scantily supplied with 
blood-vessels, but is covered with a mucous membrane showing no- 
table evidences of hyperemia, which extends also beyond the limits 
of the growth, forming a well-marked areola. It is almost always 
sessile in form. 

The favorite site for the development of a fibroma is in one of the 
vocal cords. Occasionally the growth in one cord gives rise to a simi- 
lar condition on the opposite side. Aside from this, multiple devel- 
opment does not occur. 

They present as small rounded growths, varying in size from a 
millet-seed to a hazelnut, though instances are reported in which 
the growth almost completely filled the supraglottic larynx. They 
present a smooth rounded outline, except in those cases in which the 
growth is multilobular. 

Gystomata. — Up to comparatively recent times, this form of neo- 
plasm was considered to be exceedingly rare. The inference would 
seem to be that it had either been completely overlooked or, more 
probably, its character mistaken, for it is undoubtedly of quite fre- 
quent occurrence. This form of tumor also belongs to adult life,- 
usually occurring between twenty-five and fifty. 

A cystoma is the result of an obstruction of the duct of one of the 
muciparous glands ; its secretion becomes imprisoned, and, slowly in- 
creasing, distends the cavity of the gland. This is the view usually 
entertained in regard to the development of a cystoma, although 
whether it is due to a degeneration of the epithelial lining of the 
gland and an atrophy of the duct, or is the result of certain degener- 
ative changes in the epithelial cells themselves, the duct remaining 
patent, is uncertain. 

The site of its development is usually on the epiglottis and vocal 
cords. 

It presents as a smooth, rounded, easily compressible, movable 
mass, covered with light red mucous membrane, and varies in size 
from the head of a pin to a hazelnut. 

Myxomata. — This form of tumor is met with somewhat rarely. 



742 DISEASES OF THE LARYNX. 

The growths locate themselves invariably upon the vocal cords, and 
may consist of a myxomatous degeneration, as it were, of the mucous 
membrane, giving rise to a sessile growth, or they may assume the 
form of a pedunculated multilobular growth. In some instances, 
they seem to present the ordinary smooth surface and gelatinous 
aspect of the myxomatous tumors met with in other parts of the air 
tract, while in others the surface is mammillated, of a grayish-pink 
color, and closely resembles a papilloma, from which indeed they can 
be distinguished only by microscopic examination. 

In most cases they are unilateral, although both cords may be 
invaded. 

Pathologically they are identical with similar growths in other 
portions of the air tract, being composed of loosely interlacing fibres 
of connective tissue holding within its meshes branching myxomatous 
cells. 

Angiomata. — Vascular tumors in the larynx have been reported 
by a number of observers. In the majority of cases, they spring from 
the vocal cord, although instances have been recorded in which their 
origin was in the ventricular bands, the epiglottis, the hyoid fossa, 
and the lingual sinus. They vary in size from a pea to a hazelnut, 
and are composed, as are similar tumors in other regions, of a mass 
of blood-vessels held together by loose bands of connective tissue. 
The cases reported have all occurred in adult life, and confined them- 
selves to one side, except in one case. 

Chondromata. — Instances of this form of growth have been occa- 
sionally observed. It is characteristic of a cartilaginous growth 
springing from one of the laryngeal cartilages that it extends in- 
ward, giving rise to a sessile and immovable mass, which attains 
a considerable size, thus encroaching notably upon the breathing- 
space and causing dyspnceic symptoms. Its favorite point of 
development is in the cricoid cartilage; next in the order of fre- 
quency it arises from the thyroid, the epiglottic, and the arytenoid 
cartilages. 

They are usually sessile in character, irregular in outline, and 
covered with slightly hypersemic mucous membrane, and when sub- 
jected to attrition the surface becomes eroded. They occur usually 
in adult life, and develop very slowly. They are composed purely of 
hyaline cartilage, excepting when they spring from the epiglottis, 
when there is a more or less copious admixture of fibrous tissue. In 
one of Boecker's cases, a patient aged sixty -two, the tumor had 
undergone a certain amount of ossification. They vary from the size 
of a cherry -pit to a mass more or less completely filling the laryngeal 
cavity. 



BENIGN TUMORS OF THE LARYNX. 



743 



Adenomata.— It is somewhat doubtful if this form of neoplasm 
ever occurs iu the larynx. 

Lipomata. — The development of fatty tumors in the larynx is con- 
fined, with the single exception of a case reported by Burns, to those 
cases in which the growths, taking their origin in the ary epiglottic 
fold, fall externally into the hyoid fossa, where they oitentimes at- 
tain considerable size. 

It is to be understood that in describing the various forms of neo- 
plasm which occur in the larynx we have classified them under the 
head of the prevailing histological element which enters into their 
composition. Growths in the larynx, however, follow the same rule 
which governs the development of tumors in other parts of the body, 





Fig. 161. 



-Papilloma of Right Ventricular 
Band. 



Fig. 162.— Papilloma of Ventricular Bands. 



and we not infrequently meet with cases in which other tissues are 
more or less copiously mingled with the prevailing type. 

Diagnosis. — A papilloma is soft in consistency, is movable to a 
limited extent in the acts of inspiration and phonatioD, presents a 
grayish-white or pinkish-white color, is minutely mammillated or 
wart-like in contour, and usually springs from the anterior portion 
or angle of the vocal cords. The only growth with which it need be 
confounded, probably, is epithelioma in its early stages, and in such 
cases the age of the patient will aid us in forming a correct opinion. 

A. fibroma presents the appearance of a hard resisting mass, with 
a rounded or irregularly nodulated contour, and is covered with a 
mucous membrane, more or less highly injected. It is usually sessile 
in character, and deeply embedded in the surrounding tissues. It 
springs almost invariably from the anterior portion of the vocal cords. 
It may resemble either a cvstoma or chondroma. The latter, how- 
ever, never develops upon the vocal cords, while the cystoma is soft, 



744 



DISEASES OF THE LARYNX. 



compressible, usually movable, and liable to be pedunculated. It 
moreover presents a semi-translucent aspect. A gummy tumor of 
the cords might present appearances suggestive of fibroma, and yet 
the progress and clinical history of the former should aid in* estab- 
lishing the diagnosis. 

A cystoma is a small, soft, compressible growth, usually peduncu- 
lated, of a pinkish- white or grayish-white color, according to its loca- 
tion. Thus, on the cords it usually forms an almost translucent sac, 
while when it springs from the parts above, as from the arytenoid 
commissure or epiglottis, its surface is more or less vascular, giving 
it a reddish tinge and rendering it somewhat opaque. The character 
of the growth is easily determined by the probe, or by its collapse on 
seizure with the forceps. 

A chondroma presents a hard, dense, resisting mass, of somewhat 





Fig. 163.— Papilloma of Ventricular Bands com- 
pletely filling the Vestibule of the Larynx. 



Fig. 164.— Cystoma of the Epiglottis- 



irregular outline, whose prominent characteristic is its exceeding 
slowness of development. It is covered by a healthy mucous mem- 
brane, and arises from any one of the laryngeal cartilages, although 
the cricoid is its favorite seat. In this latter situation it may be mis- 
taken for a perichondritis or carcinoma. The former disease is char- 
acterized by the suddenness of its onset, the acuteness of the local 
inflammatory symptoms, and the early development of dyspnoea, 
while the subglottic origin of carcinoma is an exceedingly rare' event. 
Moreover, the benign growth belongs to the earlier periods of life. 
A chondroma from one of the cartilages above the glottis presents 
something of the gross appearance of a fibroma. Its origin, as gath- 
ered from the clinical history, should suggest the character of the 
growth. Of course, the density of the tumor would easily distinguish 
it from the softer neoplasms, such as myxoma and cystoma. 



BEXIGN TUMORS OF THE LARYNX. 



745 



Myxoma* — Myxoma in the . larynx is of soft consistency and a 
grayish-white color. When, however, it is multiple, it presents ap- 
pearances not unlike that of a papilloma. In these instances, the 
diagnosis can he clearly established only by removing a portion of 
the tumor and subjecting it to microscopic examination. The 
growth, moreover, as in papilloma, arises almost invariably from the 
vocal cords. 

Angioma. — Angioma, constituting as it does a raspberry-like 
mass of highly injected blood-vessels, presents gross appearances 
which are unmistakable. 

Prognosis. — These growths, as a rule, involve no dangers to life, 
except in those instances in which they attain such size as to encroach 
upon the normal breathing-space; and in such a case, of course a 
fatal tendency can be counteracted by the prompt performance of 





Fig. 165.— Chondroma of the Epiglottis. 



Fia. 166.— Angioma of the Left Ary-Epiglottic Fold. 



tracheotomy. Ample warning, however, is always conveyed of any 
dangerous tendencies. 

As a rule, the presence of the growth gives rise to no marked dis- 
turbance of the other portions of the larynx, either of an inflamma- 
tory, cedematous, or a neurotic character. 

With our present methods of dealing with a neoplasm of the larynx, 
by the endo-laryngeal and extra-laryngeal operations, the prognosis 
as regards cure is practically always good. Papillomata alone show 
a marked tendency to recurrence. This is probably due to the fact 
that this variety of growth is generally subjected to the endo-laryngeal 
method of removal ; hence, in those cases in which they have attained 
considerable size, it requires exceedingly nice manipulative skill to 
thoroughly extirpate the neoplasm without injury to the soft parts. 
It is probable, therefore, that the failure thoroughly to extirpate the 



746 



DISEASES OF THE LARYNX. 



growth is in no small degree responsible for the recurrence when it 
takes place. 

The prognosis as regards the complete restoration of the voice is 
generally good, although in some cases, in which the tumor has at- 
tained a large size, its extirpation is attended with a certain amount of 
injury to the healthy tissues which is liable permanently to impair 
the voice. 

Spontaneous expulsion of the growth has been reported by some 
observers. 

The possibility of a benign neoplasm undergoing malignant de- 
generation has been the subject of somewhat extended investigation, 
it having been claimed that a spontaneous tendency to this degener- 
ation existed which was notably stimulated by the endo-laryngeal 




Fig. 167.— Mackenzie's Laryngeal Forceps. 

methods of operating. It is thus found not only that the tendency to 
spontaneous degeneration is an exceedingly feeble one, but that this 
tendency is diminished by operative interference. It is scarcely 
necessary to add that this tendency largely confines itself to papil- 
lomatous growths. 

Treatment. — Before the days of laryngoscopy, practically the 
only method of dealing with a neoplasm in the larynx, in those rare 
cases in which it was recognized, consisted in obtaining access to the 
laryngeal cavity by an external opening through the neck, although 
instances are recorded of successful operation through the natural 
passages, previous to the introduction of the laryngoscope. 

After the larynx was brought under ocular inspection, the recog- 
nition of growths, even of small size, of course became an exceed- 
ingly simple procedure. 



BENIGN TUMORS OF THE LARYNX. 747 

Various methods are employed for the extirpation of a neoplasm. 

Evulsion consists in seizing the growth bodily, and tearing it 
from its site. This is accomplished either by means of the bladed 
forceps or by what is called the tube forceps. In Fig. 167 is shown 
the Mackenzie blade forceps, in which the blades are bent at a right 
angle. They are constructed to work either antero- posteriorly or 
laterally. Fauvel's forceps are very similar, with the exception that 
the blades are curved to a segment of a circle. My own preference is 
decidedly in favor of the Mackenzie instrument, owing to the fact 
that the angle at which it is bent adds notably to the facility of manip- 
ulation. As regards the direction of the blades, I quite agree with 
Fauvel in regarding the lateral movement as oftentimes of consider- 
able advantage, in that the view of the parts is less obstructed than 
in the antero-posterior movement; the blades of Fauvel's instrument, 
moreover, are fenestrated for the same purpose. As accomplishing 
the same purpose, various forms of the tube have been devised. 
The objection to these instruments, as a rule, I think, is that they 
are not only too delicate in construction, but that the movements 
of the blades are somewhat limited, restricting their use to the 
smaller growths. The types of these are fairly well illustrated by 
Stoerk's instrument, in which the distal extremity of the tube is bent 
to the quadrant of a circle ; and in Schroetter's instrument, in which 
the tube is curved both horizontally and vertically, in such a way 
that the handle is thrown to one side and beyond the line of vision. 
The latter instrument I regard as by far preferable for conveni- 
ence of manipulation, although its use is somewhat restricted. 
The Mackenzie tube forceps I regard as entirely too slender for ordi- 
nary use. 

Crushing the growths is accomplished by the same instruments 
which are used for evulsion. 

Abscission consists in cutting through the base of the growth by 
means of a concealed knife or small scissors, such as the Stoerk and 
Schroetter instruments. 

Ecrasement is adapted only for those growths which project into 
the lumen of the larynx in such a way as will admit of the successful 
placing of a wire loop around their base. For this purpose, Schroet- 
ter's instrument or any ordinary snare may be used, the distal ex- 
tremity being bent to a proper curve to suit the individual case. 

The indications for excision by means of the guillotine are very 
similar to those for the use of the snare. The dislodgement of 
growths by means of the forcible introduction of a sponge probang 
into the larynx is recommended, and is especially suitable for small 
pedunculated growths attached near the edge of the vocal cords, 



748 DISEASES OF THE LARYNX. 

although ordinarily it would riot be resorted to except in those cases 
in which tolerance of instruments is not easily secured on the part 
of the patient. 

Destruction of growths in the larynx may be accomplished by 
either the chemical or potential cautery. Of the chemical agents, I 
much prefer the use of chromic acid to any other caustic. This may 
be fused on the end of a properly curved probe ; or, in order to pro- 
tect the healthy tissues, a hooded porte-caustique may be used. A 
very simple device is to wrap a large pledget of cotton firmly on the 
end of the laryngeal probang and then place a saturated solution 
of the chromic acid on that portion of the pledget which will impinge 
directly on that part of the growth which it is desired to destroy. 
Nitrate of silver I regard as inefficient, while the more powerful caus- 
tics, such as caustic potash, Vienna paste, and nitric acid, should 
never be used in the larynx. 

The use of the galvano-cautery in the larynx possesses this great 
advantage, that the electrode can be placed in situ before the heat is 
developed in the platinum tip, and the current opened again before 
withdrawing the instrument, thus restricting its action entirely to the 
poiut which it is desired to cauterize. Hence, in those cases in which 
the milder chemical agent is inefficient, we possess no method of de- 
stroying laryngeal neoplasms comparable to it. The size and shape 
of the electrode should be adapted to the character of the growth with 
which we have to deal, although in most instances it will be wiser to 
use the smaller-sized platinum tips, and to nicely adjust the strength 
of the current to the proper heating power. 

For the purpose of local anaesthesia, a twenty-per-cent solution of 
cocaine should be applied freely to the fauces and the larynx by 
means of the spray, and the action of the drug tested at the end of 
from three to four minutes, by passing a pledget of cotton, saturated 
with the solution, into the laryngeal cavity. 

It is to be borne in mind that local anaesthesia does not secure 
amenity from reflex contraction of the faucial muscles ; hence, when 
the membrane is rendered completely insensible, the operation may 
be hampered by involuntary muscular contractions of the fauces. 
This can be to a certain extent controlled by having the patient 
swallow some small pellets of ice during the intervals between the 
cocaine applications. 

The first step consists in bringing the neoplasm into view ; as soon 
as this is accomplished, the forceps (being previously warmed) is 
grasped firmly in the right hand, and the beak of the instrument 
passed directly into the fauces, until it nearly reaches the pharyngeal 
wall, after which it is carried down into the larvnx. This should be 



BENIGN TUMORS OF THE LARYNX. 749 

accomplished without impinging in any way upon the walls of the 
pharynx or larynx. As the beak of the instrument is passed down- 
ward and approaches the growth, it comes into view in the laryngeal 
mirror, after which its further movements are easily directed by the 
eye. 

If the growth is supraglottic, immediately before the beak of the 
forceps is turned toward the laryngeal cavity, the patient should be 
directed to take a full inspiration, and follow this by the utterance 
of a high-pitched prolonged "A," thus securing the fullest elevation 
of the epiglottis and the widest exposure of the laryngeal cavity, and 
at the same time to an extent diverting the attention of the patient. 
In some instances, the seizure of the growth may be best accom- 
plished during either expiration or inspiration, although the phona- 
tory position of the larynx will prove most favorable in the majority 
of cases. 

It is to be remembered that the depth of the larynx varies greatly 
in different individuals; it is therefore of importance that the de- 
scending portions of the blades should be of such length that the 
growth can be reached without the shaft of the instrument impinging 
upon the epiglottis. 

It is scarcely necessary to add that the forceps should be intro- 
duced closed, and opened only at the moment the growth is to be 
seized. 

I know of no operation in the throat which requires greater dex- 
terity than the removal of a growth by the endo-laryngeal method. 

A very small-sized papilloma is probably best removed by the 
Schroetter tube forceps ; for the larger growths, I think most oper- 
ators will give decided preference to the stout Mackenzie or Fauvel 
bladed forceps. These large growths are rarely removed at one sit- 
ting, but are taken piecemeal at intervals of from three or four days 
to a week, according to the tolerance of the patient and the trauma- 
tism which accompanies the operation. 

Fibromas which project prominently into the laryngeal cavity are 
probably best removed by means of the snare, while those which are 
deeply embedded are most easily reached by the cutting forceps or 
curette. It is probably wiser, in the case of small fibromas, which 
are deeply embedded and inaccessible, to let them alone, for any 
attempt at operation is liable to do injury to the parts, while the 
mere existence of the growth itself involves no special danger to life, 
and the possibility of restoring the impaired vocal function is exceed- 
ingly doubtful. 

Cystomas disappear promptly upon evacuation of the sac contents 
by the use of the concealed or naked knife. 



750 DISEASES OF THE LARYNX. 

Myxomata, whether sessile or pedunculated, should be seized and 
torn away by the bladed forceps. 

If an angioma is so located as to admit of the use of the wire loop, 
this should be employed in preference to evulsion by any form of 
forceps, for, whereas the tumor is soft and easily torn away, there is 
no little danger of exciting troublesome hemorrhage. The danger of 
hemorrhage is not entirely obviated by the use of the snare, and it 
becomes a question whether the growth might not be destroyed by the 
galvano-cautery with more safety to the patient ; or, in case the tumor 
has attained a large size, probably thyrotomy would be the more judi- 
cious procedure, either with or without a preliminary tracheotomy. 

Enchondromata of small size may be successfully dealt with by 
cauterization; the larger growths, however, as a rule, will demand 
thyrotomy. 

After the removal of a laryngeal tumor, a certain amount of after- 
treatment is generally necessary, both to destroy small fragments 
that may be left after evulsion or other methods of removal, or to 
prevent recurrence, this latter having mainly to do with papillomata. 
This consists in the application of caustics at intervals of a week or 
longer. For this purpose, probably no agent is more efficient than 
chromic acid, fused on the end of a delicate probe, after the manner 
already described. 

If more active measures for destruction are indicated, the galvano- 
cautery may be used. For those growths which cannot be destroyed 
or extirpated by endo-laryngeal methods, it will become necessary 
to obtain direct access to the tumor by an external opening into the 
larynx. The operations which have been done for this purpose are 
thyrotomy, subhyoid pharyngotomy, and infrathyroid laryngotomy. 
These operations are described in a later chapter. 

Before closing this discussion, I cite in full certain propositions 
laid down by Browne as follows : 

First. Attempts at removal of growths from within the larynx are 
not in themselves so innocuous as is generally believed; bat, on the 
contrary, direct injury to the healthy parts of the larynx, leading to 
even fatal results, is by no means of infrequent occurrence. 

Second. The functional symptoms occasioned by benign growths 
in the larynx are in a large proportion of cases not sufficiently grave 
to warrant instrumental interference. 

Third. Many of these new formations will disappear or be reduced 
by appropriate local and constitutional medical treatment, especially 
when of recent occurrence. 

Fourth. ^Recurrence of laryngeal growths after removal per vias 
naturales is much more frequent than is generally supposed. 






BENIGN TUMORS OF THE LARYNX. 751 

Fifth. While primary malignant or cancerous growths are of rare 
occurrence within the larynx, benign growths occasionally assume a 
malignant and even cancerous character, by the irritation produced by 
attempts at removal. 

Sixth. The instruments now most generally in use are far more 
dangerous than those formerly employed. 

Seventh. The cardinal law that an extra-laryngeal method ought 
never to be adopted unless there be danger to life from suffocation or 
dysphagia should be applied with equal force to intra-laryngeal oper- 
ations, and it is a subject worthy of consideration whether in many 
cases tracheotomy alone might not be more frequently performed — 
first, with a view of placing the patient in safety when dangerous 
symptoms are present; second, in order that the larynx may have 
complete functional rest; and third, as a preliminary to further 
treatment, radical or palliative. 

These statements seem somewhat radical, and while they cannot 
be fully indorsed, yet, coming as they do from so accomplished a 
writer and authority, they are not only worthy of consideration, but 
carry so much of suggestion that I simply quote them without further 
comment. 



CHAPTER XCIII. 

SAKCOMA OF THE LAKYNX. 

It is only within comparatively recent times that any close dis- 
tinction has been drawn between the two forms of malignant disease 
in the larynx, sarcoma and carcinoma. This we can easily understand 
when we consider the fact that the clinical history and prognosis are 
much the same in both forms of disease. 

Sarcoma is to be regarded as of exceedingly rare occurrence in the 
larynx. This is indicated by the fact that it stands in the proportion 
of 1 to 62 of carcinoma. 

Etiology. — Our conclusions are based on an analysis of 47 cases, 
which are recorded in medical literature. Of these, 34 occurred in 
males and but 13 in females. As regards age, 1 occurred in the sec- 
ond decade of life, or between ten and twenty ; 4 in the third, 7 in the 
fourth, 9 in the fifth, 11 in the sixth, 6 in the seventh, and 2 in the 
eighth ; the youngest of these patients being a female aged nineteen 
and the oldest being seventy-four. As a rule, the affection develops 
without any apparent cause and in patients enjoying good health. 
One case, however, seems to have developed from a simple papilloma 
of the larynx. 

Pathology. — The histological character of the growth differs in 
no essential degree from sarcomas found in other portions of the 
body. 

The disease originated in the vocal cords in 16 cases, in the ven- 
tricular bands in 9, in the right ventricle in 2, in the epiglottis in 5, 
and in the right pyriform sinus in 1. In 2 cases the origin of the 
growth was subglottic. 

In most instances the growth seems to confine itself to the laryn- 
geal cavity, and, when an extension occurs, the tendency is down- 
ward. In cases recorded the disease started in the tonsil and phar- 
ynx, in the commissure. In one unique case it invaded the larynx, 
pharynx, soft palate, and base of the tongue. As a rule, the disease 
is not only unilateral in this region, but tends to remain so. 

Symptomatology. — The earliest symptom is impairment of voice, 
giving rise to either hoarseness or complete aphonia, while, as the air 
spaces are encroached upon, interference with respiration sets in. 



SARCOMA OF THE LARYNX. 753 

There is generally more or less secretion from the surface of the 
growth ; hence, cough is usually present. This is rarely a persistent 
or distressing symptom, except when the tumor extends below the 
glottis. If the growth extends upward and involves the epiglottis or 
the parts above, dysphagia is liable to occur. 

Pain is rarely present. Erosion or ulceration is liable to occur 
quite early in its history, in which case the sputa may be tinged with 
blood, though I know of no instance in which grave hemorrhage has 
occurred. 

The rapidity of growth seems to vary notably in different cases. 
In one case it rilled the larynx in two months, and in another in four 
months. 

The tendency to generalization is exceedingly feeble, as shown by 
the fact that the cervical glands are very rarely the seat of secondary 
infiltration. In but a single instance reported has this tendency to 
generalization extended farther than the cervical glands. In this in- 
stance there was metastatic involvement of the lungs, liver, and brain, 
death occurring from these complications three months after the pri- 
mary invasion of the larynx. 

In many instances a form of cancerous cachexia seems to set in. 
This, however, rarely presents the prominent features of the carcino- 
matous cachexia. 

Diagnosis. — These growths present an irregularly rounded out- 
line, sometimes of a pinkish but generally of a grayish, semi-opaque 
color. They are soft in consistency, and their general aspect is per- 
haps best described by the term "grumous." 

We have no definite means of distinguishing by gross inspection 
between a sarcoma and a carcinoma. 

The differential diagnosis can best be established by submitting a 
portion of the growth to a microscopic examination. 

Prognosis. — The disease is an exceedingly fatal one, and only less 
so than carcinoma of the larynx. Of the 47 cases which I have col- 
lected, the histories are incomplete in most instances. In 18 death 
is recorded, and in 13 the report is complete, from which it is shown 
that the average duration of life from the onset of the symptoms was 
nineteen and one-quarter months. 

Treatment. — An analysis of the cases operated upon indicates 
that extirpation may occasionally prove successful. Instances are 
recorded in which recurrence has not taken place. 

No suggestions can be made as to the selection of an operation in 
any given case, as in each instance this decision must be based en- 
tirely on the duration of the disease and the size and location of the 
growth. In the early stages, while the tumor is small, it will be best 
48 



754 DISEASES OF THE LARYNX. 

to attempt to remove it through the natural passages ; if this fail, 
thyrotoray should be resorted to. 

Resection or complete extirpation of the larynx becomes impera- 
tive, unless specially contraindicated by the general condition of the 
patient, when the simple operations have failed to remove the dis- 
ease. 



CHAPTER XCIV. 

CARCINOMA OF THE LARYNX. 

The rarity of carcinomatous invasion of the larynx is shown by a 
report of 11,131 cases of carcinoma in three of the large hospitals of 
Vienna; in these the larynx was invaded in 63. Lebert, in 9,118 
cases of cancer, found this organ affected in but 3 cases ; Winiwar- 
ter, out of 548 cases, found 1 case of laryngeal cancer; and Baker 
finds the larynx affected 3 times in 500 cases. 

Etiology. — Heredity exercises the same important influence in 
laryngeal cancer as in other regions of the body. This is traceable 
in from twenty to twenty -five per cent of the cases reported. 

It is much more frequent in the male than in the female, and be- 
longs essentially to the late years of life. 

Occasionally a patient traces the origin of the disease to some 
over-use or strain of the voice, or perhaps to an attack of laryngeal 
catarrh. It would seem probable that these symptoms are really 
due to the onset of the malignant affection. 

Pathology. — The histological characters of laryngeal cancer do 
not differ from those of cancer in other portions of the body. By far 
the most frequent variety in this region is epithelioma. 

Cancerous growths may spring from any portion of the larynx, 
though the ventricular bands are most often affected. 

It is a well-known fact that primary cancer of the larynx, so long 
as it confines itself within the cavity, shows little tendency to involve 
the lymphatic glands of the neck. As a rule, intrinsic cancer, so long 
as it confines itself to the laryngeal cavity, does not affect the lym- 
phatic glands of the neck. Extrinsic cancer, that affecting the epi- 
glottis, ary-epiglottic folds, or the arytenoids, may extend to the 
glands at a comparatively early period. 

The investigations of Sappey have shown that the lymphatic ves- 
sels in the superior portion of the larynx are multiplied to infinity, 
forming a close network covering the epiglottis and stretching toward 
the ary-epiglottic folds. As it reaches the ventricular bands and 
lower portions of the larynx, it becomes more and more attenuated. 
This attenuation, moreover, is more evident with advanced age. 
Herein, I think, lies an explanation of the fact that malignant disease 



756 DISEASES OF THE LARYNX. 

in the intrinsic or lower portion of the larynx fails in so many cases 
to result in involvement of the cervical lymphatics. 

Symptomatology. — There is nothing in the development of a la- 
ryngeal cancer which gives rise to symptoms differing in any marked 
degree from those which characterize the onset of a benign growth. 
Yocal impairment is the first symptom which manifests itself, and 
even this may be absent for a considerable period, especially in those 
cases which commence in the ventricular bands. As the tumor in- 
creases in size, the voice becomes weaker and is finally almost com- 
pletely lost. The next symptom is dyspnoea, as the growth en- 
croaches upon the breath ing-space. In extrinsic cancer, dysphagia 
may develop, owing, in the early stages, to the mechanical obstruction 
cf the food tract by the growth. As the direct result, probably of this 
latter symptom, salivation becomes a prominent symptom in many 
cases. 

Glandular enlargement, if present, occurs somewhat early in the 
history of the case. In the course of from three to six months, the 
subjective symptoms become more prominent, and ulceration and 
hemorrhage appear. The ulceration not only involves the superficial 
parts of the tumor, but forms fissured or crater-like excavations, the 
result of interstitial necrosis. This is especially characteristic of en- 
cephaloid cancer. In epithelioma, on the other hand, the ulceration 
is more superficial in character. 

Before ulceration occurs the secretion consists merely of a slight 
excess of healthy mucus, the accumulation of which in the larynx 
may give rise to slight irritation and cough. After ulceration sets in 
the secretion becomes somewhat excessive, and consists of a thin sero- 
mucus, more or less freely surcharged with pus cells and necrotic tis- 
sue. It is of a grayish-yellow color and somewhat unhealthy aspect. 
At the same time the patient's breath is apt to be exceedingly offen- 
sive, the fetor having a peculiar musty smell. 

Hemorrhage occurs in consequence of the ulceration, and may be 
very slight, simply tinging the sputa ; or, as the result of an erosion 
of one of the arterial twigs, may be very frequent. But one case of 
fatal hemorrhage from a laryngeal cancer, however, so far as I know, 
has been reported. 

Pain is a somewhat constant symptom, although in rare instances 
entirely absent. It is more characteristic and more prominent in ex- 
trinsic cancer. It is of a sharp, lancinating character, and usually 
radiates toward the ear, although it may extend over the whole side of 
the neck. 

The cancerous cachexia is longer delayed in the laryngeal form of 
the disease, and in many instances is entirely absent. m 



CARCINOMA OF THE LARYNX. 757 

Diagnosis. — A definite diagnosis cannot be made in the early 
stages of the disease. The disease consists essentially in a cell infil- 
tration, which burrows, broadly and deeply, into surrounding parts. 
Hence, the defined tumefaction by no means shows the whole extent 
of the diseased action. As the result of the deeper infiltration, ex- 
tending to the muscles and perhaps to the articulations, the normal 
motility of the parts is liable to be seriously impaired, even at a com- 
paratively early stage of the disease. In the later stages of the dis- 
ease, the diagnosis is comparatively easy : the prominent features are 
the broadly infiltrating, irregular mass which fills the laryngeal cavity, 
the complete distortion of the parts, the extensive ulceration, the pe- 
culiar character of the secretion, and the fetid odor. These, taken in 
connection with the age of the patient, the enlargement of the cervical 
glands (if such be present), the progressive development of symp- 
toms, together with the lancinating pains radiating toward the ear, 
aud the cachexia in the very late stage, enable one to recognize the 
true character of the disease beyond much question of doubt. 

Prognosis. — Cancer in any region of the body is not only one of 
the most fatal, but one of the most distressing of diseases, and is 
rendered more so when occurring in the larynx, in that it interferes 
with respiration. Fauvel reports that in seven cases of encephaloid 
cancer of the larynx not operated upon the average duration of life 
was three years ; and in six cases of epithelioma not operated upon 
the average duration of life was one year and eleven months. It 
would seem, therefore, that it is not more rapidly fatal than cancer in 
the other portions of the body, with the exception of those involving 
the muscular connective tissue and the lymphatic tissues. It would 
be a fair inference that a cancer of the larynx would result in death 
from suffocation in a comparatively short period. We reach the con- 
clusion, therefore, that for some reason the growth develops more 
slowly in this region, or else that the early ulceration results in such 
a loss of tissue that a sufficient patency of the air passages is main- 
tained to admit of respiration for a longer period. 

Treatment. — There are certain general and local measures to be 
resorted to in the treatment of cancer of the larynx which mitigate 
in a marked way the suffering which this disease entails. These 
measures, in brief, consist in the local application, by means of 
sprays or in the form of powders, of anodynes and disinfectants. 

For the latter purpose, we may use a twenty-per-cent solution of 
peroxide of hydrogen, a one-half-per-cent solution of pyoktannin, a 
two-per-cent solution of permanganate of potash, or one of the car- 
bolized alkaline solutions, the formulae of which have already been 
given, although, for the correction of the fetor which attends cancer- 



758 DISEASES OF THE LARYNX. 

ous ulceration, no remedy probably is better than iodoform or iodol, 
preferably the former. 

For the local anodyne effect, we may use morphine, either in pow- 
der or in solution. The action of morphine, while more permanent, 
is by no means so efficient as cocaine. A five- to ten-per-cent solution 
of this latter drug may safely be entrusted to the patient for use by 
means of a suitable atomizer, as often as may be necessary . 

Liegeois reports a case in which a carcinoma of the larynx was 
apparently rendered stationary for twenty-six months by the daily in- 
ternal administration of fifteen drops of tincture of thuja occidentalis, 
together with local applications of the same drug. 

Tracheotomy, of course, is merely a palliative resort, and should 
be performed promptly upon the supervention of dyspnceic symp- 
toms. Fauvel found that this operation prolonged life nine months 
in encephaloid disease, and over two years in epithelioma. 

The radical measures of treatment embrace the use of caustics, 
endo-laryngeal operations, thyrotomy, resection, and extirpation of 
the larynx. 

The use of either the chemical or potential cautery should be con- 
demned on every ground. 

The removal of a malignant growth by the endo-laryngeai method 
would commend itself by its simplicity, and yet there is but a single 
case on record in which this method has been successful. 

In a compilation of twenty-two cases of thyrotomy, made by 
Mackenzie, a successful result was obtained in two cases, both being 
operated on by Billroth, one of carcinoma and the other of epitheli- 
oma. To these should be added two cases operated upon by Butlin, 
in which, endo-laryngeal methods failing, thyrotomy was done. 

As regards resection or partial extirpation of the larynx, Macken- 
zie has collated thirty -five cases in which this operation was done. 
Of these patients, six were wel] at the end of from twelve to eighteen 
months, while one was well nearly three years after the opera- 
tion. 

Coming now to the most radical operation, viz., the total extirpa- 
tion of the larynx, we find, according to Mackenzie, that practically 
the whole of the larynx has been removed in one hundred and thirty- 
eight cases. Of these patients one hundred died or had a recurrence. 
Of the remainder, the history of some is imperfect, but it is safe to 
infer that thirteen, or ten per cent, recovered. 

Thyrotomy can be performed with any hope of success only at an 
early period of the disease, and before the deep tissues and cartilages 
had been infiltrated. Eesection, of course, is indicated only in those 
cases in which the disease still confines itself to one side of the lar- 



CARCINOMA OF THE LARYNX. 759 

ynx, while total extirpation becomes necessary only when the whole 
cavity is invaded. 

When we consider the exceeding fatality of the affection, and the 
feebleness and uncertainty of our remedial measures, we must acknowl- 
edge that there are few questions presented to the surgeon which are 
more difficult of decision than those with which he is confronted in a 
case of laryngeal cancer. 

In any case of neoplasm in a patient past middle life, which 
shows any marked disposition to recurrence, and especially if the mi- 
croscope reveals a^ tendency to epithelial formation, there can be no 
question of the wisdom of performing thyrotomy and thoroughly ex- 
tirpating every portion of the tumor. If, upon this, recurrence takes 
place, a resection of the larynx should be promptly made while the 
disease is still confined to one side of the larynx. No question should 
be entertained in regard to the advisability of this operation, when 
we consider the successful results which have attended it and the lim- 
ited danger to life which it involves, compared with complete extir- 
pation. 

There are two questions to be considered always in these cases : 
the arrest of the disease and the comfort of the patient while life 
lasts. While, therefore, the resection may not completely eradicate 
the disease, and recurrence will probably take place, it must be borne 
in mind that we have by the operation added many months of com- 
parative comfort to the life of the patient. 

When recurrence takes place after resection, the further question 
of total extirpation of the organ is one that can be decided only ac- 
cording to the special indications in each particular case, or perhaps 
according to the wishes of the patient. 



SECTION VI. 
EXTERNAL SURGERY OF THE THROAT. 



EXTERNAL SURGERY OF THE THROAT. 



Under this heading we discuss the various surgical procedures 
which are performed for the purpose of obtaining access to the phar- 
ynx, larynx, and trachea, and which necessitate cutaneous incision. 



CHAPTER XCV. 

PHARYNGOTOMY. 



In the very large majority of cases, when the removal of a tumor or 
a foreign body from the pharynx becomes necessary, access sufficient 
for manipulative purposes is afforded through the natural passages. 
When a wide opening is required, it is a well-recognized surgical pro- 
cedure, which involves no serious complications, to enlarge the oral 
opening by an incision through the cheek, extending from the angle 
of the mouth to the anterior border of the masseter muscle. When 
tumors are of large size and extensive attachments, one of the more 
complicated operations will become necessary. 

Subhyoid Pharyngotomy. (See colored plate.) 

This operation is particularly indicated in growths situated low 
down on the pharyngeal wall, and may be resorted to in supraglottic 
tumors of the larynx not easily removable through the natural pas- 
sages. It affords a free and direct approach to the lower portion of 
the pharynx, and yet the laryngeal mirror renders this region quite 
accessible for examination and manipulation. It is only those cases 
of benign tumors, therefore, which involve unusual difficulties of 
manipulation which call for the external incision, such as a broadly 
sessile growth, perhaps, or one whose base encroaches upon the orifice 
of the oesophagus. A malignant growth also may necessitate the 
wider access and more direct manipulation which this operation 
affords. It may also be indicated for growths in the pyriform si- 
nuses. 



764 



EXTERNAL SURGERY OF THE THROAT. 



The Operation. — The patient should be i>laced on a table, with the 
shoulders elevated, as in tracheotomy, the head being bent backward 
as far as possible. A transverse incision through the integument is 
made about one-third of an inch below the lower border of the hyoid 
bone, extending from the anterior border of the sterno-mastoid mus- 
cle on one side to a similar point on the opposite side (see Fig. 168). 
Beneath the skin we come upon the superficial fascia, in which 
courses the anterior and occasionally the external jugular veins. 
These are to be included between two double ligatures, and severed. 
Beneath the superficial fascia the sterno-hyoid muscles are met with 




,. — ??* nw '• illi »:• ^-« ;---•-- 



Fig 168.— The Cutaneous Incision in Subhyoid Pharyngotomy, and the Relation of the Deeper 

Parts. 

in the median line, one on either side, and cut through, and, beneath, 
the thyro-hyoid muscles, which are treated in the same manner. The 
thyro-hyoid membrane is then reached, dense in the median line but 
becoming more attenuated laterally. The wound should be now ex- 
plored by the thumb and index finger, and the attempt made to ascer- 
tain the position of the epiglottis. "When this is found, the thyro- 
hyoid membrane and the pharyngeal mucous membrane which is 
beneath it should be incised at the side of the epiglottis, and the in- 
cision carried directly through to the opposite side, care being taken 
to avoid wounding either the epiglottis or its attachments. The crest 
of the epiglottis is now seized and drawn out through the wound, 
when a stout thread should be passed through it and a loop formed ; 
it is then drawn downward and forward by an assistant in such a way 



PHAR YNGOTOMY. 



765 



as to leave wide and free access to the pharyngeal cavity. If now, on 
direct examination and palpation of the growth which has called for 
the operation, it is found to extend downward into the oesophagus, a 
special advantage of the procedure lies in the fact that more space can 
be gained by extending the end of the incision on one or the other 
side down along the border of the sterno-mastoid muscle, in such a 
way as to convert the procedure practically into a lateral pharyngot- 
omy, or, more correctly perhaps, an cesophagotomy. 

After the growth has been removed, the wound is closed by insert- 
ing catgut sutures into the thyro-hyoid membrane and- the severed 




Fig. 169.— Line of Cutaneous Incision in Lateral Pharyngotomy (Langenbeck's Method). 

muscles, and finally bringing together the cutaneous flaps and treat- 
ing them in a similar manner. 

The patient should now be restricted to rectal alimentation for at 
least forty -eight hours. 



Lateral Pharyngotomy. {See colored plate.) 

Langenbeck's Method. — A curved incision (see Fig. 169) is made 
through the integument, which, commencing at the lower border of 
the inferior maxilla, midway between the chin and angle, then passes 
downward to the superior cornu of the hyoid bone, and along the an- 
terior border of the sterno-mastoid muscle to a point opposite the cri- 



766 



EXTERNAL SURGERY OF THE THROAT. 



coid ring, or lower if necessary. Immediately beneath the integu- 
ment the platysma muscle, lying in the superficial fascia, is divided. 
Beneath this is found the deep cervical fascia, which is to be incised 
with some care, especially in the upper portion, where important ves- 
sels and nerves may be encountered. In the lower portion of the 
wound, however, the only vessel which may be met with is the supe- 
rior thyroid; this should be avoided, while the sheath of the great 
vessels is retracted. Beneath the deep fascia in the upper portion of 
the wound the submaxillary gland is seen and pushed to one side, 
when the hyo-glossus muscle comes into view and is severed, and the 




Fig. 170.— Line of Cutaneous Incision in Lateral Pharyngotomy (Bergmann's Method). 

lingual artery, which courses beneath it, sought for and ligated. Af- 
ter this, the stylo-hyoid and digastric muscles are severed and the 
greater cornu of the hyoid bone is found, beneath which lies the 
pharyngeal aponeurosis, which being incised, with the mucous mem- 
brane beneath it, the pharyngeal cavity is reached. When the phar- 
ynx is opened, the incisions through its lateral wall may be extended 
as far up as the base of the tongue and down to the orifice of the 
oesophagus, thus obtaining a wide access to this region for the carry- 
ing out of the indications for which the operation is done. This 
method is especially valuable for the removal of tumors involving the 
lower portion of the pharynx and even extending into the oesophagus, 



PHAR YNGOTOMY. 



767 



in that this latter structure can be opened through a considerable por- 
tion of its upper extremity. Moreover, by strongly retracting the 
anterior flap, the posterior wall of the larynx is brought thoroughly 
within reach ; and when this has been invaded by the morbid proc- 
ess its resection is easily accomplished. 

Bergm ann's METHod. — A curved incision, with its convexity out- 
ward (see Fig. 170), is carried backward from the angle of the mouth, 
across a point near the angle of the jaw, and downward over the su- 
perior cornu of the hyoid bone and along the anterior border of the 
sterno-mastoid muscle to a point opposite the thyroid cartilage, or 




Fig. 171.— Line of Cutaneous Incision in Lateral Pharyngotomy (Kuster's Method). 

lower if necessary. After the integument and superficial fascia are 
cut through, the facial artery should be sought for and ligated, after 
which, the muscles of the cheek being divided, the lower portion of 
the wound is deepened and the lingual artery ligated in the manner 
already described in Langenbeck's operation. The ramus of the jaw 
is now sawn through in the line of the cutaneous incision. The mu- 
cous membrane is then incised from the angle of the mouth backward 
and downward to the pharyngeal cavity. In this manner a wide and 
continuous access is obtained to the whole of the cavity of the mouth 
and pharynx as far as the laryngeal orifice. 

Kuster's Method. — A cutaneous incision, commencing at the an- 



768 



EXTERNAL SURGERY OF THE THROAT. 



gle of the mouth, was carried backward across the angle of the jaw to 
the anterior border of the sterno-mastoid muscle (see Fig. 171) . The 
cheek was completely cut through, some small branches of the facial 
artery being encountered and ligated ; the ramus of the jaw was then 
exposed and sawed through in the line of the incision. The upper 
fragment was then disarticulated and removed. The incision was 
carried through the mucous membrane back as far as the border of 
the sterno-mastoid muscle. By depressing the jaw and retracting the 




Fig. 172.— Line of Cutaneous Incision in Lateral Pharyngotomy (Mickulicz's Method"). 



upper flap, abundant access was obtained to the faucial region and 
cavity of the pharynx. 

The same surgeon suggests that, in case the disease extends down- 
ward toward the oesophagus, the horizontal incision might be made 
from the corner of the mouth to the angle of the jaw and then contin- 
ued vertically downward to the border of the sterno-mastoid muscle, 
the upper fragment of the jaw being removed in the same manner as 
in his first operation. 

Mickulicz's Method. — In this operation an incision is made 
through the integument of the side of the neck, extending from the 
mastoid process along the anterior border of the sterno-mastoid mus- 
cle down as far as the thyroid cartilage (see Fig. 172) . The integu- 



PHARYNGOTOMY. 



769 



merit and superficial fascia being cut through, the deep fascia is 
reached, after which the dissection should be made with exceeding 
great care. Beneath this we come upon the great vessels, which are 
to be retracted. The facial artery should now be sought for and 
ligated, and the hypoglossal nerve carefully avoided. The anterior 
flap is retracted, and the angle of the jaw sought for and cleared. 
The periosteum of the ascending ramus is carefully separated, care 
being taken to preserve the insertion of the pterygoid muscles. The 
ramus is then sawn through and disarticulated. The lower portion 
of the incision is now deepened, the posterior belly of the digastric 




Fig. 173.— Line of Cutaneous Incision in Lateral Pharyngotomy (Cheever's Method). 

muscle divided, the stylo-hyoid drawn forward, and the lateral wall 
of the pharynx thus reached, which is now opened in its whole extent 
from a point opposite the soft palate down as far as the oesophageal 
entrance, if necessary. 

Cheever's Method.— In a case of encephaloid tumor of the tonsil, 
this operator opened the pharynx after the manner already described 
in Mickulicz's operation, with the exception that the ramus of the 
jaw was not resected and a little wider retraction of the flaps was ob- 
tained by making, in addition to the longitudinal cutaneous incision, 
a horizontal incision extending forward along the body of the inferior 
maxilla (see Fig. 173) . 
• 49 



770 



EXTERNAL SURGERY OF THE THROAT. 



In a second case operated upon by the same surgeon, the incision 
was carried from the angle of the mouth backward in a straight line 
across the ramus of the jaw to the anterior border of the sterno-mas- 
toid muscle. The ramus was then sawed through and the fragments 
separated. An incision was then made through the mucous mem- 
brane, extending backward through the whole extent of the cutaneous 
incision. 

Polaillon's Method. — This surgeon, in order to gain access to a 
malignant tumor of the tonsil, incised the cheek from the angle of the 




Fig. 174.— Line of Cutaneous Iucisiou in Lateral Pharyngotomy (Polaillon's Method). 

mouth backward, and extended his cutaneous incision across the infe- 
rior maxilla as far as the anterior border of the sterno-mastoid mus- 
cle. A segment of the ascending ramus of the jaw was excised, and 
then the cutaneous incision was extended downward along the ante- 
rior border of the sterno-mastoid muscle (see Fig. 174) . The inci- 
sion through the mucous membrane thus extended from the mouth in 
a straight line to the pharyngeal wall and subsequently down to the 
orifice of the oesophagus. 



CHAPTER XCVL 

THYKOTOMY. 

[See colored plate.] 

The infrequency of the resort to this procedure before the days of 
laryngoscopy is easily explained by the inability to make a definite 
diagnosis of intra-laryngeal conditions, and hence the failure to estab- 
lish clear indications for opening the larynx. 

Indications. — This operation is usually done for the removal of 
tumors in the cavity of the larynx; in rare instances it may be indi- 
cated in the cases of foreign bodies in this cavity, and possibly for 
cicatricial stenosis or other morbid conditions. Hope has suggested 
its availability for the purpose of removing a portion of the vocal 
cords in cases of abductor paralysis, to re-establish impeded respira- 
tion. 

When a tumor can be thoroughly extirpated through the natural 
passages without involving any danger of permanent injury to the 
soft parts, there can be, of course, no question as to the propriety of 
such procedure. If the tumor is of large size and has a broad base, 
or if it is attached beneath the cords, or in any other position which 
renders it not easily within the reach of the laryngeal forceps, there 
should be no hesitancy in opening the larynx, in preference to sub- 
jecting the patient to the dangers which the intra-laryngeal method 
might entail. 

The Operation. — The incision is made through the integument in 
the median line, extending from immediately above the thyroid notch 
to the cricoid ring. The integument being retracted and the small 
amount of areolar tissue which is found in this region being pushed 
aside by the handle of the scalpel, the thyroid cartilage is brought 
immediately into view. This should be thoroughly cleared and its 
extent in the median line recognized, both by the contour of the parts 
and the position of the thyroid notch, when with a stout sharp scal- 
pel a superficial incision is made, extending throughout its whole 
length. This is slowly deepened by successive strokes of the knife 
until the mucous membrane is reached. In late adult life this carti- 
lage is liable to be the seat of ossification, which will necessitate the 



772 



EXTERNAL SURGERY OF THE THROAT. 



use of a small saw or the cutting forceps. The mucous membrane 
should be thoroughly exposed by a complete section of the cartilage 
before it is cut or the larynx penetrated, inasmuch as the irritation and 
hemorrhage are liable to cause a troublesome cough, by which subse- 
quent manipulations may be hampered. The constant effort should 
be to confine the incisions exactly to the median line : this is of es- 
pecial importance in incising the mucous membrane, for a devia- 
tion from the median line at this step of the operation would involve 
the wounding of one of the vocal cords. In order to avoid this, it is 
well to make the incision from below upward by means of a curved 
sharp-pointed bistoury, the fragments of the cartilage being held 
apart by means of hooks in the hands of an assistant. A short inci- 













Fig. 175.— Cutaneous Incision in Thyrotomy, and its Relation to the Underlying Structures. 

sion is made first, when the subglottic tissues and under surface of 
the vocal cords are brought into view, provided a strong light is used, 
and this operation should always be done, I think, with the aid of the 
concave forehead mirror. As soon as the vocal cords are seen, the 
knife can be so directed as to complete the incision of the mucous 
membrane directly between the anterior insertion of the cords. In 
making the cartilaginous section, it is well to leave a small portion of 
the cartilage at the upper extremity of the incision undivided, to pro- 
vide for the more perfect coaptation of the parts after the completion 
of the operation. If a sufficiently roomy access to the laryngeal cav- 
ity is not obtained in this way, it may be necessary to complete the 
section, in order that the halves of the divided cartilage may be 
drawn farther apart. 



THYROTOMY. 773 

As gaining still larger access, it may occasionally be wise to make 
a transverse incision through the crico-thyroid membrane at the low- 
er border of the thyroid cartilage. When cutting in this region, of 
course, the position of the crico-thyroid artery crossing the upper 
portion of this membrane should always be borne in mind. 

The cavity of the larynx being now opened, the neoplasm is 
brought into view and removed by such measures as may seem most 
suitable. Ordinarily, I think, the cold-wire snare, or for a very small 
growth the ordinary aural snare, should be resorted to, as securing 
the detachment of the tumor with the least amount of hemorrhage. I 
cannot agree with Mackenzie in considering this operation as " a very 
serious one as regards the danger to life," for in itself it involves no 
very grave menace to life, nor is it liable to be attended with grave 
complications. The most troublesome complication which may arise 
is that of hemorrhage. As a rule, this arises in the extirpation of 
the neoplasm, and not from the thyrotomy incisions. The hemor- 
rhage which occurs at the time of the operation is not excessive, and 
usually can be controlled by pressure, or, if necessary, by ligatures. 
The slow trickling, or perhaps secondary hemorrhage, which occa- 
sionally occurs later, is liable to be more troublesome even than the 
primary bleeding. This is best controlled by thorough cauterization 
of the base of the tumor, either by the galvano-cautery, nitrate of sil- 
ver, or chromic acid. Of these the former is probably the best hae- 
mostatic, if used at a dull red heat. 

It is by no means an easy matter in these operations, especially 
in young children, to thoroughly recognize the regional anatomy of 
the laryngeal cavity when opened in this manner. This is especially 
true while the neoplasm is in position. After the growth has been 
removed, however, the false cords and ventricular openings should be 
easily recognized. Perhaps as valuable a landmark as any will be 
found in the arytenoid cartilages, which when the growth is removed 
can be seen in the deepest portion of the opening, moving rhythmi- 
cally with the respiratory act. Their recognition enables the oper- 
ator more intelligently to explore the cavity, and to verify the suc- 
cess of the operation in the complete removal of every trace of 
neoplasm. 

After the growth has been extirpated, the cartilaginous structures 
are brought again into as perfect apposition as is feasible, and se- 
cured in place by sutures. In a child these should be of silkworm 
gut, as they are to be left in situ. The integument is then brought 
together and secured above them. 

The decision of the question of a preliminary tracheotomy is 
one which will be based largely upon the character of the affection 



774 EXTERNAL SURGERY OF THE THROAT 

which calls for the thyrotomy. If the tumor is of small size, and pre- 
sents a fair prospect of allowing of extirpation without much hemor- 
rhage, it will probably be safe to open directly into the larynx with- 
out previously inserting a tracheal canula. In most instances, 
however, this latter procedure will be demanded, and whether abso- 
lutely necessary or not, it certainly adds much to the sense of security 
with which the surgeon will operate ; moreover, his manipulation is 
notably aided by abolishing for the time being the respiratory func- 
tion of the larynx, by temporarily establishing a new channel for the 
air current below. 

I know of no good reason why the two operations should not be 
done at the same time, as the shock from both procedures combined 
can scarcely react on the general system to such an extent as seri- 
ously to complicate or imperil the ultimate result. 



CHAPTER XCVIL 

TRACHEOTOMY. 

[See colored plate.] 

We use the term tracheotomy, as a somewhat generic expression, 
to describe the various operations which are done for the relief of 
dyspnoea whether the immediate site of the incision be the laryngeal 
cartilages or the tracheal rings. 

The Tube. — In the tubes formerly used, the movements of the neck 
caused the distal end of the tube to impinge upon the tracheal wall 
in such a way as to create no little irritation ; this suggested the de- 
vice in which the tube is attached to the cervical joint, by which this 
objection was obviated. Its mechanism, which is illustrated in Fig. 
176, is generally known as Trousseau's. 

An oval opening is ordinarily made on the upper side of the 
curved portion of the tube, opposite the lumen of the upper segment 
of the trachea; this is designed to ad- 
mit the passage of air for respiratory pur- 
poses when the inner tube is withdrawn. 

A very serious objection to this fenes- 
tra lies in the fact that the tissues are 
apt to pouch into the opening and become 
eroded; and in several instances I have 
seen exceedingly troublesome hemor- 
rhages arise from this source. The object r 

° J Fig. 176.— Trousseau's Tracheal Tube. 

of the fenestra, of course, is to enable 

the patient by closing the mouth of the tube to force air through 
the larynx, either for phonatory purposes or to test the patency of 
this organ. Ordinarily there is sufficient space between the periph- 
ery of the tube and the tracheal wall to admit of this. 

The ordinary tube is curved to the arc of a quadrant, and for this 
reason cannot adapt itself to the varying thickness of the cervical tis- 
sues. To obviate this difficulty, Durham has constructed the exceed- 
ingly ingenious device shown in Fig. 177. The improved feature of 
this tube consists in making that portion of it which lies in the wound 
straight, while the tracheal end is bent somewhat abruptly to a right 




776 



EXTERNAL SURGERY OF THE THROAT. 



angle ; at the same time, in order to adapt it to the varying depth of the 
trachea beneath the integument, it is so arranged that the position of 
the neck-plate can be changed, thus altering the length of that portion 
of the tube which is in the wound and adapting it for any special case. 
Of course this short curve in the tube demands that the inner canula, 
in order to permit of removal and insertion, shall be flexible. This is 
accomplished by constructing the tracheal end of the inner tube with 
lobster-tail joints, as shown in the figure. It is also supplied with a 
pilot trocar with a jointed extremity, to facilitate its introduction. 
Theoretically, Durham's tube is a great improvement on the ordinary 

form : its advantage lies in the 



fact that in the movements of 
deglutition the whole tube 
moves upward in the axis of the 
trachea, carrying with it the 
tracheal end, which is thus 
prevented from tilting against 
the posterior wall. The mov- 
able neck-plate renders it pos- 
sible to adapt the tube nicely to 
the varying thickness of the cer- 
vical tissues, and to adjust its 
proximal opening to the axis of 
the trachea. The jointed inner 
canula presents crevices for the 
lodgment of mucus, hence it is 
somewhat liable to become 
clogged ; there is also a danger 
showing the that the segments may become 
detached and drop into the 
trachea. Moreover, the removal and reinsertion of the outer tube, 
after the wound in the neck has closed around it, is attended with a 
distention of the parts, which renders it necessary to crowd the tis- 
sues to such an extent that hemorrhages may be excited. With the 
Koget tube, by passing it exactly in the line of the circle of which it 
forms a quadrant, no lateral pressure whatever is exerted, and the 
tube is removed and reintroduced with perfect ease, and without 
causing pain or hemorrhage. With the Durham tube, on the other 
hand, which is passed through a straight opening until it reaches 
the trachea, its convexity crowds upon the upper wall, while its 
tracheal extremity scrapes along the floor of the wound till it reaches 
its position. 

Fuller has devised an instrument in which the outer tube consists 




Fig. 177.— Durham's Tracheal Tube 

lobster-tail inner tube and the pilot trocar. 



TRACHEOTOMY. 



777 




of two lateral convex plates attached firmly to the neck-plate. The 
supposed advantage of this device is that, by pressing the plates to- 
gether, the point of the instrument is reduced to a minimum, thus 
facilitating its insertion into the tracheal opening. These plates are 
subsequently forced apart by the insertion of the inner tube. Gen- 
dron has devised a similar instrument, in which the lateral segments 
of the outer tube are separated by means of a screw fixed to the outer 
plate. These devices possess no especial advantages, and, moreover, 
the edges of the segments are liable to cause erosion of the tissues in 
the wound. In Fig. 178 is shown an instrument 
devised by Koenig, for cases in which the respir- 
atory stenosis occurs low down in the trachea. 
The instrument is about four and a half inches 
long. The firmness and flexibility necessary for 
its introduction are secured by making its central 
portion of wire wound into close spiral. 

When tracheotomy has been done for a syphi- 
litic stenosis or other chronic affection of the 
larynx, valves are occasionally fitted to the canula 
in such a way that, while inspiration is effected 
through the tracheal opening, the expiratory cur- 
rent is forced through the natural passages. In 
Fig. 179 is shown the Luer pea valve, which is 
fitted to the tracheal canula. During inspiration 
the ball is lifted away from the orifice of the tube, 
and the inspiratory current passes easily, while 
during expiration it falls into the outer opening, 
completely closing it, and thus forcing the air 
through the larynx. 

Various devices have been constructed for rapid 
tracheotomy, on the principle of the canula and 
trocar. I do not think this method of operating 
is to be commended. 

Tracheal canulas are constructed of silver, alu- 
minum, and vulcanite. The metal tube should in all cases be pre- 
ferred, for, while the vulcanite canula is cheaper, it is fragile and 
brittle, and there is always the danger of a fracture in the effort to 
withdraw an inner tube which has become fixed by dried mucus; 
moreover, the calibre of these tubes is not so large in proportion 
to the outer diameter as in the metal instruments. 

As regards the tube to be used in any given case, the following 
table indicates the sizes admissible for the various ages : 

For a child under three years the inner calibre of the tube should 



Fig. 178.— Koenig's Tube 
for the Relief of Tra- 
cheal Obstructions. 



778 



EXTERNAL SURGERY OF THE THROAT. 



be ^g- inch ; from 3 to 6 years, T \ inch ; from 6 to 9 years, T % inch ; 
from 9 to 12 years, T \ inch ; from 12 to 20 years, T \ inch. 

The largest-sized tube which is supplied by the instrument makers 
has a calibre of a half-inch. This is very rarely used, however. 

Instkuments. — The instruments required for operating are a 
sharp scalpel or bistoury ; two hooks, either blunt or sharp-pointed, 
for separating the edges of the wound ; a sharp hook for fixing the 
trachea ; a grooved director ; and two pairs of ordinary thumb forceps. 
In addition to these, it is well to have within reach a number of artery 
clamps, an aneurism needle, curved and straight blunt-pointed scis- 
sors, silk and catgut ligatures of as- 
sorted sizes, and curved and straight 
needles. 

Indications. — Among the diseases 
which produce narrowing of the lumen 
of the larynx, thereby interfering with 
respiration, and which maij demand the 
operation, are oedema of the larynx, 
acute submucous laryngitis, acute and 
chronic subglottic laryngitis, syphilitic 
and tuberculous laryngitis, neoplasms 
of the larynx, foreign bodies in the 
larynx, fracture of the larynx, double 
abductor paralysis, and spasm of the 
larynx in children and, in rare instances, 
in adult life. It also maj r be demanded to gain access to foreign bod- 
ies in the trachea or bronchial tubes, and as preliminary to laryngot- 
omy, laryngectomy, and other operations upon the upper air tract. 

It should be borne in mind that a long continuance of laryngeal 
stenosis is liable to develop a weakness of vasomotor control in the 
blood-vessels of the bronchial mucous membrane, and thereby entail 
a danger of the sudden supervention of pulmonary oedema. On this 
account, as well as others, the greatest safety to the patient is secured 
by an early resort to the insertion of a tracheal canula. Moreover, 
the operation in itself is not one which is attended with any very 
grave dangers to life, and does not usually seriously complicate the 
disease for the relief of which it is performed. 

The Use of Anesthetics. — The trachea is frequently opened with- 
out anaesthesia when the symptoms are of such an urgent character 
as to demand immediate relief. If such urgency does not exist, how- 
ever, there can be no question as to the propriety of securing that 
perfect relaxation and control of the patient, as well as the freedom 
from pain, which the anaesthetic affords. 




Fig. 179.— Tracheotomy Tube fitted 
with Luer's Valve. 



TRACHEOTOMY. 779 

Ether is exceedingly irritating to the mucous membrane of the 
air tract ; it is liable to produce nausea and vomiting ; it requires 
usually from ten to twenty minutes to secure perfect relaxation ; the 
stage of excitement is frequently prolonged ; and, moreover, in most 
cases it produces that troublesome churning movement of the larynx 
which proves a serious obstacle to the operator. The only argument 
in favor of this agent is its safety. 

Chloroform, on the other hand, is unirritating to the air tract; it 
excites no movements in the larynx ; it is rapid in its action ; and it 
produces complete anesthesia usually in from three to six minutes. 
Clinical experience teaches us that the danger attending its use, al- 
though not entirely absent, is very much less in child life than with 
adults. Unless, therefore, some special contraindication is present 
in the form of cardiac or other general disease, this agent should be 
given the preference in opening the trachea in children. In my own 
experience this has been the only anaesthetic used, and I have in no 
single instance seen any unfavorable symptoms develop from its 
administration. 

The hypodermatic injection of twenty minims of a four-per-cent 
solution of cocaine into the integument immediately over the site of 
the cutaneous incision will produce sufficient anaesthesia to enable the 
surgeon to insert a tracheal tube with comparatively little pain, with 
the exception possibly of the last incision through the mucous mem- 
brane of the trachea. Injected in this way, the anaesthesia is main- 
tained for from ten to twelve minutes, which ordinarily is an abundant 
time for completing the operation. This method, therefore, would 
seem to be an admirable resource when tracheotomy is demanded in 
adult life. It is a wise precaution to have chloroform or ether pro- 
vided for use, in case of unexpected complications setting in which 
would demand either extension or prolongation of operative measures. 

As regards the mixture of one part alcohol, two parts chloroform, 
and three parts ether, I have had but limited experience, but am dis- 
posed to regard it as quite as irritating to the mucous membranes of 
the air tract as pure ether. Another method is to administer chloro- 
form until relaxation is secured, and subsequently to use ether. 
Chloroform anaesthesia does not prevent the unpleasant effects of 
ether; hence I do not think this method is to be commended in 
tracheotomy. 

Regional Anatomy of the Parts. — Immediately beneath the in- 
tegument covering the larynx and trachea anteriorly we come upon 
the superficial fascia, in which course from above downward the two 
anterior jugular veins, between the median line and the anterior 
border of the sterno-mastoid muscles, lying on either side of the 



780 



EXTERNAL SURGERY OF THE THROAT 



former about two-fifths of an inch distant from it. Just above the 
sternum they communicate by a transverse trunk. They vary in size 
in different subjects, and one is occasionally wanting. Their division 
may give rise to troublesome hemorrhage. Immediately beneath the 
superficial fascia we come upon the sterno-hyoid muscles above and the 
sterno-thyroid muscles below, the former being in apposition over the 
thyroid cartilage and first and second rings of the trachea, namely, 
above the thyroid isthmus, while below this point the sterno-thyroid 
muscles are in apposition. Separating these, we come down upon 
the deep cervical fascia, a dense membrane which is attached to the 

li3 r oid bone above and, passing downward 
over the thyroid cartilage, the crico-thy- 
roid membrane, the cricoid cartilage, and 
the upper rings of the trachea, arrives at 
the upper border of the isthmus of the 
thyroid gland, where it divides into two 
layers, one passing in front and the other 
behind the isthmus, to reunite on its 
lower border. The thyroid isthmus is 
usually described as lying upon the sec- 
ond and third rings of the trachea, al- 
though, according to Koenig, in most 
instances in young children it extends as 
high as the lower border of the cricoid 
cartilage. Hueter, describing this portion 
of the deep fascia which invests the thy- 
roid isthmus, designates it as the " laryngo- 
thyroid fascia," describing it as binding 
the isthmus to the lower part of the larynx 
and upon the trachea. Boese, however, 
has demonstrated that the fascia does 
not bind the isthmus directly upon the trachea, but rather 
holds it suspended over it, for if a transverse incision is made 
through the fascia above the point where it divides for inclos- 
ing the isthmus, the latter body can easily be lifted off the trachea. 
The practical point thus made by Boese is that, in the performance 
of tracheotomy above the isthmus, the tracheal rings in this way 
can easily be reached for incision and the insertion of a tube, 
without wounding the isthmus. A long, slender prolongation of the 
thyroid gland, called the pyramid, occasionally rises from the upper 
border of the left side of the isthmus, and may ascend along the side 
of the trachea as far as the hyoid bone. In rare instances this pyra- 
mid arises from the central portion of the isthmus, and is found in 




Fig. 180.— Diagram showing the Re- 
lations between the Larynx and 
Trachea and the Great Vessels of 
the Neck. 



. TRACHEOTOMY. 781 

the median line. If found, this can easily be pushed to one side. 
Our main interest with the thyroid body lies in the fact that if it is 
wounded exceedingly troublesome hemorrhage may ensue. The 
veins which are found in the deep fascia are the superior and inferior 
thyroid veins. Above the isthmus these are small, somewhat unim- 
portant, and lie so far to one side of the median line that they in no 
way are liable to complicate an operation. Below the isthmus and 
immediately over the trachea, we find a somewhat close network of 
veins, which carry the blood from the two lobes of the thyroid gland 
downward to empty into the innominate vein. This is called the 
intra-thyroid plexus. This plexus varies greatly in size, but should 
always be searched for in performing low tracheotomy, and, 
when found, the veins clamped and ligated before incision; other- 
wise, dividing them may give rise to exceedingly troublesome 
hemorrhage. 

The only normal artery which is of importance in any of the 
forms of tracheotomy is the crico-thyroid, which crosses the crico- 
thyroid membrane. This is liable to be cut when the incisions are 
carried in this neighborhood. If it is borne in mind that this artery 
hugs somewhat closely the lower border of the thyroid cartilage, it can 
easily be avoided in making the incision. 

Arterial Anomalies. — In a few cases, a small artery, designated by 
Neubauer as the arteria thyroidea ima, runs from the arch of the aorta 
along the front of the trachea to the lower border of the thyroid. 
The possibility of its existence should be borne in mind in connec- 
tion with low tracheotomy. 

The innominate artery, which normally crosses the trachea at 
about the level of the sternal notch, occasionally reaches so far into 
the cervical region as to become involved in the danger of wounding 
in low tracheotomy. According to Burns, it may reach as high as 
the lower border of the thyroid gland. Five cases have been reported 
by Burns in which both external carotids arose from the innominate 
artery. Thus, the left carotid necessarily crossed in front of the 
trachea. 

Selection of the Operation. — In selecting the point of incision 
for the insertion of the tube, certain considerations are always to be 
borne in mind which weigh for and against each location in any 
given case. There are four operations which we group under the 
general designation of tracheotomy ; these are : crico-thyroid laryn- 
gotomy, which consists in the insertion of a tube through the crico- 
thyroid membrane; laryngo-tracheotomy, in which the incision is 
made through the cricoid ring and the first ring of the trachea ; supra- 
thyroid tracheotomy, in which the incision is made through two or 



782 EXTERNAL SURGERY OF THE THROAT. 

more tracheal rings above the isthmus of the thyroid gland; and 
infra-thyroid tracheotomy, in which the incision is made into the 
trachea below the thyroid isthmus. In addition to these, the incision 
may be made directly through the isthmus, either from necessity or, 
perhaps, accident, constituting what is designated as median trache- 
otomy. The insertion of the tube through the crico-thyroid mem- 
brane is rarely resorted to. The only consideration which weighs in 
its favor is the fact that cartilaginous incisions are thus avoided. 
Furthermore, in this operation there is a certain danger of wounding 
the crico-thyroid artery. 

Laryngo-tracheotomy is perhaps the operation most frequently 
performed, for the reason that the cricoid cartilage lies almost imme- 
diately beneath the skin, and the procedure is thus much simplified. 
The objection to this operation is that this cartilage may be ossified; 
the pressure of the tube may result in cartilaginous necrosis ; and, 
furthermore, it is to be borne in mind, if the operation is done for 
the relief of a diseased condition of the larynx, that the tube projects 
into the lower portion of this cavity, and hence its presence may ag- 
gravate the morbid process. Moreover, the insertion of the canula at 
this point, encroaching so closely upon the vocal cords, may give 
rise to subsequent vocal impairment. 

In general, it is safe to state that those forms of tracheotomy 
which involve incisions through the laryngeal tissues have little to 
commend them, possess practically no advantages over a supra-thy- 
roid tracheotomy, and in most instances are objectionable. If, how- 
ever, the thyroid isthmus be found high up on the trachea, and not 
easily separated and depressed, incision through the cricoid ring is 
not only fully warranted, but may become necessary. 

The supra-thyroid operation is the one to be performed probably 
in the large majority of instances, on account of the facility with 
which it is done, the trachea at this point not being very deepty em- 
bedded beneath the integument, and because it affords us a point for 
incision sufficiently remote from the diseased condition which de- 
mands it to fulfil all indications. 

Infra-thyroid tracheotomy is the most difficult of all the opera- 
tions, from the fact that the trachea at this point is more deeply em- 
bedded in the areolar tissue of the neck, especially in young children. 
Theoretically, this is the operation which should be performed in 
most cases. The surgeon, however, will select the higher operation 
in many cases, simply as avoiding the difficulties which are liable to 
be met with in the lower incision. If, however, the operation is done 
for diphtheria, it is a matter of special importance that the tube 
should be inserted as far awav from the pseudo-membranous exuda- 



TRACHEOTOMY. <83 

tion as possible. This consideration should also operate in cases of 
malignant disease of the larynx. 

When the wearing of the canula is liable to become a permanent 
necessity, as in cases of paralysis, tumors, tertiary syphilis, or other 
grave and incurable laryngeal affections, it is probably the wiser 
course to insert the tube below the isthmus, as in this position it in- 
volves less irritation and discomfort to the patient than if inserted 
higher up. In bronchocele, of course, the tracheal incision should 
be as low down as feasible. 

Median tracheotomy is never indicated, and is only done as a 
matter of necessity, as, for instance, when the isthmus is high up 
and the lower tracheal incision is contraindicated from the presence 
of the arteria thyroidea ima, a high innominate artery, an anomalous 
course of the left carotid, or some other cause. 

It is scarcely necessary to add in this connection that when the 
symptoms are urgent, and immediate suffocation seems threatened, 
the surgeon will select that operation which is performed with the 
greatest promptness and facility. Anatomical regions are recog- 
nized only when the operation is done with deliberation and by slow 
dissection. In an urgent case, therefore, these are necessarily ig- 
nored, and if the thyroid body is wounded it can scarcely be a matter 
for criticism. 

The Operation. — The patient should be placed on a long, narrow 
table, so situated as to afford the operator abundant light. The 
shoulders should be elevated and the head thrown back, in order to 
render the integument tense and to bring into prominence the larynx 
and trachea, as far as possible. For this purpose, a hard pillow, or 
better still, perhaps, a rolling-pin around which several thicknesses 
of a towel have been wrapped, should be used. Two or three assist- 
ants should be present, or, better still, four — one to administer the 
anaesthetic, one to sponge, one to manage the instruments, and a 
fourth to directly assist the operator; for, although in many 
cases this operation is undoubtedly an exceedingly simple one, 
dangers and difficulties may arise at any moment which will 
demand quickness of decision and promptness of action, and 
these requirements will be better met when abundance of assistance 
is at hand. 

Before beginning the operation, the neck should be washed first 
with soap and water, and subsequently bathed in a corrosive-subli- 
mate solution, one part in two thousand. The instruments should 
be thoroughly disinfected by boiling, and placed ready for use in a 
tray containing a two-per-cent. solution of carbolic acid. 

The technique in these different operations is much the same in 



784 



EXTERNAL SURGERY OF THE THROAT. 



its successive steps, and we therefore describe the lower operation 
first, as involving the greater detail. 

Infra-Thyroid Tracheotomy .—The cervical integument being placed 
upon the stretch, the general regional anatomy is mapped out by as- 
certaining the position of the thyroid notch and the crico-thyroid 
space, the latter being usually felt as a depression below the thyroid 
cartilage. If the subcutaneous areolar tissue is scanty, each individ- 
ual ring of the trachea also may be located by the touch. The cuta- 
neous incision (see Fig. 181) is made with the scalpel, extending in 











. m 







-*&&Z0&^.; 



Fig. 181.— Diagram showing the Line of Cutaneous Incision in Infra-Thyroid Tracheotomy, and the 
Relation of the Underlying Structures. 



the median line from the lower border of the cricoid cartilage down- 
ward toward the sternum for from an inch and a half to two inches or 
longer, according to the age of the patient and the apparent thickness 
of the areolar tissue. There is no objection to a free incision through 
the skin, as the facility of the operation is aided by obtaining abun- 
dant room for manipulation. 

After the integument has been cut, the subsequent steps of the op- 
eration should be done by somewhat careful dissecting, and with but 
limited use of the knife. The integument, together with the super- 
ficial fascia which has been cut through with the skin, is now sepa- 
rated by the handle of the scalpel, and the sterno-thyroid muscles 
brought into view, after pushing aside such areolar tissue as may 
present in the wound. The muscles are now separated by the handle 
of the scalpel, and held apart by retractors in the hands of an assist- 



TRACHEOTOMY. 785 

ant. This brings into view the deep fascia which covers the trachea 
below and separates into two layers above, one passing in front and 
one behind the thyroid isthmus. This latter body is now recognized 
through the thin anterior layer of the fascia as a pinkish-red mass, 
lying upon the second and third rings of the trachea. The deep 
fascia should now be seized, opposite the lower border of the thyroid 
isthmus, with the mouse-toothed forceps, lifted up, and nicked with 
a knife or pair of scissors. A grooved director should then be passed 
beneath it, from above downward, and, the fascia being raised, any 
blood-vessels that it may contain are thus brought into view and li- 
gated or clamped, as may seem preferable. The fascia being incised 
upon the director and drawn apart by the retractors, we come down 
now upon the trachea, covered with a certain amount of loose cellular 
tissue through which course the veins which compose the thyroid 
plexus. 

The wound should now be explored by the index finger, and the 
trachea and tissues immediately about it palpated to detect the pos- 
sible existence of any pulsating vessels. The cellular tissue covering 
the trachea with its veins is now pushed aside with the index finger, 
or better still, perhaps, with the handle of the scalpel, and the 
trachea brought into view. This is now seized by a sharp hook, 
lifted from its bed, and brought under closer inspection, when, if its 
anterior surface is found free from blood-vessels, an incision is made, 
by means of the sharp-pointed bistoury, sufficiently long to admit of 
the insertion of the tube (see colored plate) . 

The edges of the tracheal wound should now be held apart by 
means of the dilators, and the patient be allowed to cough, to expel 
such blood as may have made its way into the air tract. 

Occasional^, when the trachea is first opened and held open in 
such a way as to enable the patient to respire fully, a single deep in- 
spiration is taken, after which breathing seems to cease for a time. 
This is not an unusual occurrence, but to an inexperienced operator 
might excite serious apprehension, 

The tube is now inserted and secured in situ by means of the 
tapes about the neck, when the wound is closed and the integument 
brought together by proper sutures. 

The use of tracheal dilators or a pilot trocar to facilitate the in- 
sertion of the tube, I do not think necessary. Some surgeons advise 
that two silk threads be passed through the trachea, one on either 
side of the median line, and that subsequently the incisions be made 
between them ; in this way the edges of the wound can be drawn 
apart for the insertion of the tube; and, moreover, it is claimed that 
the mucous membrane, being enclosed in the loop, is less apt to be 
50 



786 . EXTERNAL SURGERY OF THE THROAT. 

pouched in the primary tracheal incision. This latter accident is one 
that can easily happen, but when it occurs it should be recognized 
and promptly corrected by a subsequent incision, either with the 
sharp-pointed bistoury or curved scissors. 

Accidents and difficulties such as this, which arise during the per- 
formance of this operation, are in many instances, I think, in no 
small degree the result of imperfect illumination. The light from 
an adjacent window may be so concentrated by a concave reflect- 
ing head-mirror as to illuminate thoroughly the parts, and thus 
enable the operator to recognize anatomical relations. 

A number of writers have advocated in certain cases the propriety 
of dispensing with the tube after the operation. The procedure con- 
sists in inserting either silk or wire sutures into the edges of the in- 
cision, and maintaining traction by uniting the threads at the back of 
the neck. Wyeth, in a case of foreign body in the bronchus, success- 
fully sutured the tracheal rings to the integument. The main advan- 
tage in dispensing with the tube is that, in case of a foreign body in 
the air tract, it is more easily expelled when dislodged, and in cases 
of fibrinous exudation, also, the membrane, when detached, is voided 
with greater facility. As securing the same object, Braatz has de- 
vised an instrument which he calls a tracheal speculum ; this is prac- 
tically an automatic retractor, whose action does not differ notably 
from the tracheal retractor of Minor, shown in Fig. 158. 

There can be no question of the propriety of temporary resorts of 
this kind. In ordinary cases, however, I think the surgeon will feel 
a greater sense of security, after a successful tracheotomy, when a 
suitable canula is properly inserted and firmly secured in situ than 
when impromptu dilators are used or sutures are inserted, which 
must necessarily require careful and constant watching. We do not 
usually consider the maintenance of the tube in position as a matter 
of any great difficulty, and yet when tracheotomy is done on a young 
child, the displacement of the tube is an accident the possibility of 
which should always be borne in mind. When this occurs, the rein- 
sertion of the canula may be attended with no little difficulty, and in 
many instances will necessitate the complete reopening of the wound. 
As avoiding this danger and as a precautionary measure, I think it 
well in all cases during the performance of the operation to insert a 
silk thread or, better still, a silver wire into the trachea on either 
side of the incision. A loop is then formed, which is carried out 
upon the neck and allowed to remain. If in such a case dyspnceic 
symptoms supervene, and in the investigation of them it seems wise 
to remove the tube, this can be done with perfect safety, and the 
patency of the trachea maintained by traction of the sutures. Further- 



TRACHEOTOMY. 



787 



more, this very markedly facilitates the reintroduction of the canula. 
In this manner, the removal of the tube can safely be trusted to an 
attendant. An additional advantage lies in the fact that, if false 
membrane in the trachea becomes detached or invaginated, thus pro- 
ducing dyspnoea, the prompt removal of the tube will usually facilitate 
its expulsion. 

Supra-Thyroid Tracheotomy. — In this operation the cutaneous in- 
cision (see Fig. 182) commences in the median line opposite the mid- 
dle of the thyroid cartilage and extends downward from two to three 
inches, as may seem necessary. On cutting through the superficial 







Fig. 182.— Diagram showing the Cutaneous Incision for Opening the Air Passages above the 
Thyroid Isthmus, and the Relation of the Underlying Structures. 



fascia the sterno-hyoid muscles are met with and separated by means 
of retractors in the hands of an assistant. This brings into view the 
deep fascia, with the thyroid isthmus showing through it in the lower 
portion of the wound. The parts are now thoroughly cleared, by the 
use of the scalpel handle, of such areolar tissue as may be found, 
when an inspection of the wound will enable the operator to deter- 
mine the relation of the isthmus to the tracheal rings. If sufficient 
room is found for the insertion of the tube, the deep fascia is incised 
longitudinally in the median line and retracted, whereupon the 
trachea is reached. If, however, the thyroid isthmus lies high up, it 
will be necessary to make a transverse incision through the deep fascia, 
over the cricoid cartilage, above the isthmus, and of sufficient length 
to admit the handle of the scalpel. This is then inserted from above 



788 EXTERNAL SURGERY OF THE THROAT. 

and passed down between the thyroid isthmus and the trachea, and 
the former lifted and pressed downward in such a way as to expose 
the first two or three tracheal rings. The space thus gained is se- 
cured by means of a retractor, after which the trachea is seized with 
a tenaculum and the first two or three rings incised. The subsequent 
steps differ in no essential degree from those already described in 
the performance of the lower operation. 

Laryngo- Tracheotomy . — This operation differs from the one last de- 
scribed only in the fact that the incision is carried upward through 
the cricoid ring and into the crico-thyroid membrane. The serious 
objection to it lies in the fact that it involves a comparatively exten- 
sive cartilaginous section, and may result in necrosis of the cricoid 
from the pressure of the tube. Moreover, it encroaches upon the 
larynx. It is very rarely performed, and its main justification is in 
a case of abnormally high position of the thyroid isthmus, which 
does not admit of a lower incision. It is very rare, however, that 
this body cannot be sufficiently depressed to permit incision through 
the upper rings of the trachea. 

Crico-thyroid Laryngotomy. — In this operation the incision into 
the air passages is confined to the crico-thyroid membrane. It is an 
exceedingly simple operation, may be rapidly performed, and is 
practically unattended by hemorrhage. Hence, it is especially val- 
uable when the urgency of the case is very great. 

It can be resorted to only temporarily, however, because the tis- 
sues of the larynx are far more sensitive than those of the trachea, 
and a tube in this position is not easily tolerated, and may not only 
excite inflammatory reaction but interfere with local function. More- 
over, this space will admit of only a comparatively small tube. In 
performing the operation, an incision is made in the median line, ex- 
tending from the thyroid notch downward from an inch to an inch 
and a half. This is carried well through the integument, which 
being drawn aside, the thyroid and cricoid cartilages are exposed. 
Such areolar tissue and superficial veins as are found are pushed aside 
by the handle of the scalpel, and the crico-thyroid membrane brought 
into view. This is punctured vertically, and subsequently a transverse 
incision is made through the whole extent. The crico-thyroid artery, 
running closely upon the lower border of the thyroid cartilage, is 
easily avoided, with a knowledge of its position. The possibility of 
the extension of the thyroid isthmus to this region is always to be 
borne in mind. 

Median Tracheotomy. — If it becomes necessary from any cause to 
insert a tube into that portion of the trachea which is covered by the 
thyroid isthmus, it seems scarcely necessary to say that our first 



TRACHEOTOMY. 789 

efforts should be either to depress or to raise this body in such a 
manner as to give sufficient access to the tracheal rings for incision. 
Failing this course, two ligatures should be passed beneath the isth- 
mus, one on either side, and the part ligated in such a manner as to 
permit of its being divided in the median line, after which the re- 
maining steps of the operation can be easily concluded in the manner 
already described. 

Rapid Tracheotomy. — The operations above described involve care- 
fulness of detail and recognition of anatomical relations. It may be 
necessary occasionally, either on account of the urgency of the case 
or the necessity of doing the operation without sufficient light to 
enable the operator to recognize the anatomical relations, to perform 
what is called a rapid tracheotomy. 

The larynx and trachea are firmly grasped between the thumb and 
first two fingers of the left hand in such a way as to draw them for- 
ward from the spinal column, while at the same time the skin is ren- 
dered somewhat tense and immovable over the parts. A bistoury is 
then plunged directly through the crico-thyroid membrane, and then 
by a sawing movement the cricoid cartilage and the upper rings of 
the trachea are cut through from within outward. In withdrawing 
the knife, the cutaneous incision is extended down somewhat farther. 
The tube is then immediately inserted. Durham seizes the larynx in 
the same manner, pulls it forward, and cuts from without inward, 
making his incisions rapidly until the tracheal cartilages are reached, 
when he either opens the windpipe in the same way or seizes it with 
a tenaculum and opens it more deliberately. While these operations 
may be rendered necessary in certain cases, they certainly cannot be 
commended as surgical procedures. 

After-Treatment. — When a canula is inserted into the trachea, 
the important functions of the nasal chambers with reference to res- 
piration are practically abolished, and hence the after-treatment in 
any case of tracheotomy consists in such measures as will, as far as 
possible, supply the deficiency in warmth and moisture which the 
operation has entailed, and absence of extraneous matters in the in- 
spired air. 

In an acute case, and in all cases for a certain period after the 
tube has been inserted, the room should be kept at a temperature of 
fully 75° F. ; it should be fully surcharged with moisture ; and in addi- 
tion to this the tube should be covered with a number of layers of thin 
gauze, which should serve to filter the inspired current of air, without 
in any degree hampering the free entrance of air to the lungs. In 
addition to this, the gauze should frequently be moistened, in order 
that the inspired air may as far as possible be thoroughly saturated 



790 EXTERNAL SURGERY OF THE THROAT. 

When a tube is inserted for a chronic laryngeal stenosis, with the 
prospect of its being either a prolonged or permanent necessity, the 
precautions above detailed should for the while be borne in mind, 
and to a certain extent carried out. Even in such a case as this, 
however, nature seems to adapt itself in a remarkable way to new 
situations, and certainly, in my own experience of such cases, the 
canula seems to be worn with a certain degree of immunity to the 
mucous membrane of the air tract, the only precaution that is neces- 
sary being that the mouth of the tube should be covered with a few 
thin folds of gauze or silk, to prevent the entrance of insects or float- 
ing impurities in the atmosphere. 

Removal of the Tube. — There are certain accidents which may 
result from the wearing of a tube which interfere with its withdrawal, 
even after the disease for which the trachea has been opened has sub- 
sided. A number of cases have been observed in which granulations 
sprung up about the wound to such an extent as to cause notable 
stenosis. This, of course, only occurs after the tube has been worn 
for a considerable period. After the passage of air through the 
larynx has been abolished for a considerable period, its sudden resto- 
ration by the removal of the tube and the closing of the tracheal 
wound may excite a glottic spasm. Another accident, though rare, 
is bilateral paralysis of the abductors. How this should occur it is 
difficult to understand. It might possibly result from the insertion 
of a tube through the cricoid cartilage, or from local changes the re- 
sult of the presence of a canula. If the respiratory movements of the 
glottis were abolished by opening the trachea, the abductor muscles 
might undergo degeneration from lack of use. In withdrawing the 
tube, the larynx should be thoroughly examined by means of the 
laryngoscope and its patency observed, as well as the laryngeal move- 
ments, and especially should granulations be sought for. Of course, 
before removing the canula, the patency of the air tract should al- 
ways be tested, by simply closing the mouth of the tube, as in most 
instances there is abundant breathing-space around its periphery, 
even when a fenestrated canula has not been used. In no case 
should the tube be retained longer than is absolutely necessary, 
since the longer the tube is in situ the greater the danger of granu- 
lations forming. When they occur, they should be destroyed by 
efficient cauterization or, if necessary, by the use of the curette. 
These granulations, of course, are subglottic, and the manipulation 
necessary for their destruction is made through the tracheal opening. 
Occasionally it may become necessary to reopen the original wound, 
to obtain free access to the trachea for their complete ablation. 



CHAPTER XCVIIL 

EXTIRPATION OF THE LARYNX. 

[See colored plate]. 

Probably no operation in our day illustrates more strikingly the 
daring and skill of modern surgery than the successful extirpation of 
the larynx in the human subject. To Czerny is due the credit of 
demonstrating the feasibility of this procedure in the human subject, 
as the result of a successful series of experiments on dogs. Accept- 
ing Czerny 's conclusions, Billroth performed the operation with 
such a degree of success that laryngectomy was immediately placed 
among the recognized and justifiable surgical procedures in cases of 
malignant disease of the larynx. 

Indications for the Operation. — In addition to carcinoma and 
sarcoma, the larynx has been extirpated for syphilitic cicatrices, 
papilloma, lupus, and perichondritis. When we consider that in it- 
self the operation involves not only immediate and grave dangers to 
life from shock and hemorrhage, and also that it may be followed bj" 
serious complications, such as pneumonia, pleurisy, and septicaemia, 
the propriety of subjecting a patient to these dangers becomes a 
serious question, unless life be threatened by the gravity of the laryn- 
geal disease. Moreover, a prudent surgeon would scarcely assume 
the responsibility of operating in malignant disease of the larynx 
unless the morbid process was still largely confined to the laryngeal 
cavity. 

Restricting, then, the indications for laryngectomy to malignant 
disease of the larynx, it seems scarcely necessary to add that an early 
resort to surgical interference, when the diagnosis is thoroughly es- 
tablished, offers the best hope for the relief of the patient. 

The Operation. — When a tracheal canula has not already been 
inserted, many operators advise that a preliminary tracheotomy be 
done from one to two weeks before the more radical operation is at- 
tempted. This would be a wise procedure when the vital powers of 
the patient are depressed by the deficient oxygenation which a long- 
continued laryngeal stenosis might entail. If, however, this special 
indication does not exist, I see no objection to inserting the tracheal 



792 EXTERNAL SURGERY OF THE THROAT. 

tube at the same time the laryngectomy is performed. A number of 
operations have been done without the insertion of any tracheal tube, 
a properly fitting tube being at hand for insertion into the proximal 
end of the trachea as soon as this is divided in the operation. The 
advantage of this latter procedure lies in the fact that the air pas- 
sages are not opened until the trachea is cut through. In this way 
one of the greatest difficulties in the performance of the operation is 
avoided, namely, the flow of blood into the trachea, which might 
give rise to serious dangers and complications. In order to avoid 
this flow of blood into the trachea during the operation, a number of 
specially devised instruments have been constructed. In Fig. 183 is 
shown Trendelenburg's apparatus, which consists of an ordinary 



Fig. 183. —Trendelenburg's Apparatus. 

tracheal canula fitted for about a half an inch of its distal extremity 
with a rubber sheath. The small canula, to which a rubber pipe and 
bulb is attached, is so arranged that air can be forced between the 
tube and the rubber sheath in such a way as to inflate the rubber, 
thus filling up the space between the tube and the inner wall of the 
trachea and preventing the passage of blood into the parts below. 
An inhaling apparatus is also connected by a rubber tube with the 
upper extremity of the tracheal canula, thus facilitating the adminis- 
tration of the anaesthetic at a distance from the operator. I have 
used this apparatus in a number of instances, but never with satisfac-. 
ton, the distention of the sheath seeming to arrest respiration. 
Whether this is the result of reflex action from pressure on the 
tracheal membrane, or from the rubber sheath extending over and 
blocking up the distal end of the tube, I am in doubt. A more effi- 
cient and less objectionable device is that of Gerster, seen in Fig. 
184, which consists of a number of delicate steel springs placed lon- 
gitudinally around the lower end of the tracheal canula and covered 
by a rubber sheath. By turning a thumbscrew attached to the upper 
extremity of the neck-plate, these springs are made to bulge outward 



EXTIRPATION OF THE LARYNX. 793 

in such a manner as to completely fill the intervening space between 
the canula and the tracheal wall. It is provided with an inhaling ap- 
paratus similar to that of the Trendelenburg device for administer- 
ing an anaesthetic. Michael accomplishes the same result by 
firmly attaching a properly fashioned piece of compressed sponge to 
the lower end of the canula, and covering it with gold-beaters' skin, 
attached below but not above. After insertion, the moistening of 
the sponge causes sufficient swelling to tampon the trachea. Hahn, 
on the other hand, simply invests the tracheal end of the tube with a 
layer of compressed sponge which has been impregnated with a 
saturated solution of iodoform and ether, omitting any external 
covering. 

If the trachea is cut through at the earlier part of the operation, 
as before suggested, the lower segment is pulled forward and a tube 



Fig. 184.— Gerster's Tampon Canula. 

inserted, and hence these devices are unnecessary. If, on the other 
hand, the first dissections are made about the upper portion of the 
larynx, blood necessarily will enter the air tract, and hence some 
form of tampon canula will be rendered absolutely essential. In such 
cases preference, I think, should be given either to Gerster's device 
or to that suggested by Michael. 

The details of the operation are as follows : A longitudinal inci- 
sion is made through the integument in the median line, extending 
from the hyoid bone to the third or fourth ring of the trachea. If 
high tracheotomy has previously been done, the incision will neces- 
sarily be extended into the original wound. If low tracheotomy has 
been done, it will be better that an interval of normal integument 
should be, temporarily at least, allowed to intervene. In order to 
obtain wider access to the region for later manipulation, an additional 
incision may be made transversely along the line of the hyoid bone, 
at the upper end of the longitudinal incision (see Fig. 185) . The 
soft tissues covering the thyroid cartilages are now pushed aside by 
means of the handle of the scalpel, and the whole cartilaginous frame- 
work of the larynx gradually uncovered by this means and by dissec- 



794 



EXTERNAL SURGERY OF THE THROAT. 



tion. The first artery encountered is the cricothyroid, which should 
be ligated. If the morbid process in the larynx is still intrinsic and 
does not involve the external tissues, perhaps the best method to 
follow now is to incise the perichondrium from the supra-thyroid 
notch downward in the median line and separate it from the cartilage, 
first on one side and then on the other. With the removal of the 
perichondrium, the overlying muscles are detached en masse. This 
separation can be done with the ordinary elevator, or perhaps with 
the handle of the scalpel. This perichondria! separation is carried 





X | *&-! • i , ;) 

Fig. 185. — Line of Cutaneous Incision for Excision and Resection of the Larynx, with the Relative 
Position of the Deeper Structures. 



backward to the posterior border of each thyroid ala, and the same 
process repeated on the cricoid ring. After this has been done, the 
transverse incision is deepened, and the thyro-hyoid membrane ex- 
posed and incised along the upper border of the thyroid cartilage. 
The superior laryngeal artery is cut by this incision, and will re- 
quire ligation, or.it may be sought for and a double ligature placed 
about it previous to division. The thyroid cartilage is then freed in 
such a manner that it can be pulled somewhat forward by means of a 
blunt hook, when by digital exploration the superior cornu is found, 
with the lateral thyro-hyoid ligament, which is cut through. The 
same process is now repeated on the opposite side. 

The subsequent steps will depend on whether the epiglottis shall 
be removed or left in situ. The earlier operators endeavored to leave 
this organ, with the idea that its special function might be preserved. 



EXTIRPATION OF THE LARYNX. 795 

Clinical experience Las shown that even in cases in which the malignant 
process has not attacked this portion of the larynx, its function is 
practically abolished, for no artificial apparatus has yet been de- 
vised to which the epiglottis can adapt itself in preventing the en- 
trance of food into the larynx. Practically it is a hindrance rather 
than a help in the subsequent management of the case. It will prob- 
abl} r be better, therefore, in most instances, to remove it with the 
other portions of the larynx, without regard to the question whether 
it is involved in the diseased action or not. If it is left in position, 
the subsequent steps of the operation will consist in carrying the in- 
cision through the thyro-hyoid membrane directly across from one 
side to the other, following closely the upper border of the car- 
tilages, thus cutting directly through the epiglottic petiolus. If the 
epiglottis is to be removed with the remaining portion of the larynx, 
the thyro-hyoid incision is carried higher up near the lower border 
of the hyoid bone, in order to avoid severing the epiglottic attach- 
ments. The larynx now is held in position only by its attachments 
to the yielding oesophagus, and hence is easily tilted forward to a 
considerable extent, when its posterior wall is brought into view with 
the oesophageal entrance. The larynx is now drawn forward by means 
of a volsellum, and its attachments severed posteriorly by careful dis- 
section. The most serious accident that can occur at this stage of the 
manipulation lies in the danger of " buttonholing " the oesophagus. 
This is avoided by inserting the index finger or a sound into this pas- 
sage, and conducting the subsequent dissections with this as a guide, 
taking care always that the edge of the knife shall incline forward and 
be made to follow closely the laryngeal cartilages. In this way the 
dissection is carried on from above downward, until the whole of the 
larynx is cleared from its posterior attachments down as far as the 
first ring of the trachea, or lower if necessary. During this dissec- 
tion we encounter the middle laryngeal artery, which is to be treated 
in the same manner as the superior laryngeal. The point of tracheal 
section having been decided upon, the operation is completed by cut- 
ting through the trachea at such point, two sutures having previous- 
ly been inserted into the trachea below the selected point of section, 
for the purpose of attachment to the integument. The destruction of 
the tracheal support in the removal of the larynx may give rise to 
one of the most serious complications which follow the operation, in 
that, on account of the removal of these attachments, the trachea has 
a tendency to sink into the thorax. This is avoided in the manner 
above stated, by suturing the lower fragment to the integument. An 
additional security can be afforded also in those cases in which a low 
tracheotomy has been done, by suturing the edges of the incision at 



796 EXTERNAL SURGERY OF THE THROAT. 

this point to the integument, although, if the canula has been in situ 
for some time, the cicatricial adhesions which have resulted from the 
wound will of course do away with any indications for suturing at 
this point. 

In the above operation, as we have seen, the only notable arteries 
encountered are the superior and middle laryngeal arteries and the 
inferior laryngeal or crico-thyroid artery. In a case, therefore, of 
intrinsic cancer which has assumed large proportions the above opera- 
tion is accomplished without the danger of troublesome hemorrhage. 
Laryngectomy is generally regarded as an exceedingly bloody opera- 
tion. This applies to those cases in which the morbid process has as- 
sumed large proportions, and has resulted in an extensive distortion 
of the organ, as a result of which small arterial branches have acquired 
considerable size and are encountered in unexpected places. Un- 
doubtedly the advantages are decidedly in favor of operating from 
above downward, for in this way the incision into the air tract 
is made the last step of the operation, thus very largely avoiding the 
danger of blood flowing into the trachea. Moreover, it would seem 
that the extent of the diseased process can be more easily estimated 
by commencing the operation above, and the extent of the operation 
decided upon with a greater degree of nicety, than when the manipu- 
lation is done in the reverse way. 

The exigencies of the case or perhaps the choice of the surgeon 
may dictate the advisability of commencing the operation below. In 
this case the general steps are much the same as those already de- 
scribed, only the procedure is reversed. In this operation the pre- 
liminary tracheotomy may be dispensed with. The primary incision 
is made as before described. The trachea is then uncovered, drawn 
forward by a tenaculum and incised at the point of section, when, the 
lower fragment being drawn forward, a tube is inserted, and subse- 
quently the upper fragment is lifted from its bed and the dissection 
carried on from below upward. In this manipulation the lower frag- 
ment is to be secured to the integument by means of sutures, as be- 
fore, especial care being taken that the canula should be so inserted 
into the trachea, and so tightly tamponed, that no blood can pass 
into the air passages. 

The operation, of course, will necessarily vary in different cases, 
according to the special conditions which present. The extent of 
diseased action cannot always be determined accurately before opera- 
tion, and the surgeon will be compelled to vary both his primary inci- 
sion and his subsequent dissections, according as the disease may be 
found to have extended into the pharynx, or perhaps to the base of 
the tongue above, or into the oesophagus below, or according as the 



EXTIRPATION OF THE LARYNX. 



797 



necessity presents for dissecting out diseased lymphatic glands, 
wherever found. 

Aeter-Treatment. — After the operation has been completed, and 
all hemorrhage or oozing has ceased, the wound should be thoroughly 
cleansed by a corrosive-sublimate solution of the strength of 1 to 
5,000. The whole wound then is packed with iodoform gauze, a soft 
rubber catheter having previously been inserted into the oesophagus 
and the tracheal canula maintained in position. The looser folds of 
integument at the extremities of the original cutaneous incision may 
be drawn together by a few sutures. The main portion of the wound, 
however, should be left open and 
supported by temporary dressings. 
Food and drink for the first few 
days should be administered entirely 
through the oesophageal catheter, 
although at the end of the fourth 
day the patient should be encour- 
aged to make the attempt to take 
some fluid through the natural pas- 
sages. If low tracheotomy has been 
previously done, the tube should 
remain in position for three or four 
days after the operation, when it 
can be removed and the patient 
allowed to breathe through the up- 
per opening of the trachea, if feas- 
ible, or possibly it may be neces- 
sary to insert a tube at this point, 
the local dressings being modified 
to admit of this. During the fol- 
lowing fortnight the closest attention 
will be demanded to meet such con- 
ditions as may arise and to give such aid to the patient as may 
be possible, as he gradually adapts himself to the new conditions 
which the removal of such an important organ has entailed. The 
stomach tube is removed at the end of the fourth or fifth day, and as 
the patient acquires the ability to swallow naturally it may be left out 
permanently, although its frequent reintroduction may be necessary, 
either through the wound or through the mouth. The healing proc- 
ess goes on somewhat rapidly, and at the end of two or three weeks 
the parts will have assumed, under the process of cicatrization, some- 
what of their ultimate contour, when an attempt may be made to 
supply an artificial apparatus to take the place of the organ which 




-Gussenbauer , s Artificial Vocal 
Apparatus. 



798 EXTERNAL SURGERY OF THE THROAT. 

has been removed. This of course should not be attempted too 
early, for the impact of the metallic instrument is liable to produce 
erosions and possibly serious hemorrhage. 

The Artificial Larynx. — The efforts made to fit an artificial ap- 
paratus to supply the place of the organ which has been removed 
have not usually been attended with notable success, although in a 
number of instances the patient has been enabled to articulate clearly, 
and thus to carry on a conversation with considerable ease. In Fig. 
186 is shown the apparatus devised by Gussenbauer. It consists 
practically of an ordinary tracheal canula, B, to which is fitted a sec- 
ond tube, A, extending upward and opening into the pharyngeal cav- 
ity. There is thus established a continuous channel, by means of 
which the respiratory current of air can be directed up to the oral 
cavitjr. By inserting the vibrating reed into the continuity of this 
channel, and closing the cervical aperture of the canula, this expira- 
tory current is thrown into vibrations which are subsequently con- 
verted into articulate language by the lips, tongue, etc., as in the 
normal process. A serious difficulty which has been encountered in 
fitting these devices has been in preventing the oral and pharyngeal 
secretions, as well as food and drink, from making their entrance into 
the air passages from above. This is not successfully accomplished 
bjr the epiglottis, as a rule, when this organ has been left in situ. 
Gussenbauer fitted an artificial epiglottis to the upper end of the oral 
tube, in the form of an automatically closing hinged cap, which 
served a fairly successful purpose. A modification of Gussenbauer's 
instrument has been devised bv Park. 



CHAPTER XCIX. 

RESECTION OF THE LARYNX. 

[See colored plate.'] 

This term is generally used to designate the more or less complete 
removal of one lateral half of the larynx ; although technically it may 
include any operation which involves removal of any portion of the 
laryngeal cartilages. 

The indications for the operation are practically confined to in- 
stances of malignant disease which have not become generalized, and 
to cases of syphilitic stenosis. The amount of tissue to be removed, 
therefore, and the parts to be excised will necessarily vary to a 
certain extent in each individual case. 

The Operation. — A longitudinal incision is made through the 
integument in the median line, extending from the hyoid bone to 
below the cricoid ring. The upper extremity of the incision is then 
extended horizontal^- on the side which it is desired to remove, as far 
as the greater cornu of the hyoid. The longitudinal incision is then 
carried well down upon the thyroid cartilage, when the lateral flap 
is dissected up, together with the perichondrium of the thyroid carti- 
lage. The arteries encountered are the superior, middle, and in- 
ferior laryngeal or the crico-thyroid, and may need ligation. When 
the thyroid ala has been completely denuded of its perichondrium as 
far back as its posterior border, the cartilage should be cut through 
in the median line, as in thyrotomy, thus gaining free access to the 
laryngeal cavity. The edges of the wound should now be thoroughly 
retracted and the cavity of the larynx explored, the extent of the 
diseased process recognized, and the various landmarks established, 
to aid in the subsequent manipulation. These points having been 
determined, the attachment of the thyro-hyoid membrane along the 
upper border of the cartilage should be severed, when the ala is 
seized by a stout pair of forceps, drawn well forward, and its attach- 
ments posteriorly and inferiorly cut through, either by means of a 
bistourj r or better still perhaps with the curved scissors. The wound 
should now be carefully dried, and an effort made to determine how 
much of the lining membrane of the larynx, or what diseased tissue, 



800 EXTERNAL SURGERY OF THE THROAT. 

has been extracted with the fragment already removed. Usually the 
incision will have extended through the ventricular band, and also 
anteriorly through the vocal cord. The orifice of the oesophagus 
should now be sought and a sound inserted, when the arytenoid 
cartilage can be seized and excised by means of the scissors. The 
further steps of the operation consist simply in searching for evi- 
dences of the morbid process, and the removal of such portions as 
excite suspicion of having been invaded. 

As a rule, when a simple exsection rather than laryngectomy is 
indicated, the morbid process will not have invaded the epiglottis. 
If this organ is diseased, of course it can be completely excised 
or one-half of it removed by means of the scissors. If the cricoid 
cartilage is found invaded, its removal in a manner similar to that of 
the thyroid ala involves no special difficulties. 

As regards the preliminary insertion of a tracheal canula, the 
same rule applies as in the case of complete extirpation of the 
larynx : there can be no question that the previous introduction of a 
tracheal tube greatly simplifies the operation. 

Aftee-Treatment. — After the operation is completed, the wound 
should be packed with iodoform gauze, and the flaps brought together 
and supported by loose adhesive strips. Deglutition is somewhat 
difficult and perhaps painful, but by no means impossible, after this 
operation; and although occasionally it may be necessary to make 
use of the stomach tube for the first twenty -four to forty-eight hours, 
the patient very soon is enabled to swallow fluids effectively and 
with no great discomfort. At the end of the second or third day an 
attempt should be made to close the external wound, although if there 
is much suppuration it may be wise to insert a small drainage tube 
in its lower portion. During the first few days the tampon canula is 
to be retained in position in order to prevent the entrance of the dis- 
charges into the air tract. As soon as feasible, the ordinary fenes- 
trated canula should be tried and the attempt made to breathe 
through the natural passages. 

The effect of removing half of the larynx is necessarily to destroy 
the voice, and yet, as the parts heal, the effort of nature to adapt 
herself to the new conditions is attended by no little success, in 
that not infrequently the tissues of the diseased side solidify to such 
an extent that the approximation of the healthy vocal cord to them 
forms a glottis capable of producing a fair degree of phonation. 



INDEX. 



Abscess, of the nasal septum, 172 
peritonsillar, 418 
retropharyngeal, 404 
Accessory cavities, differential diagnosis 
between the diseases of the. 274 
sinuses of the nose, 43 
diseases of the. 250 
involvement of, in acute rhi- 
nitis, 66 
Acute catarrhal inflammation, 27 
Adenoid growths in the vault of the 

pharynx, 299 
Adenomata of the larynx, pathology of, 
743 
of the nasal passages, 237 
Albuminuria in croupous tonsillitis, 451 
Anaesthesia of the larynx, 695 
Anaesthetics in tracheotomy, 778 
Anatomy of the fauces, 367 
of the larynx, 575 
of the naso -pharynx, 279 
of the nose, 41 
Angioma of the larnyx, diaguosis of the, 
745 
pathology of the, 742 
treatment of the, 750 
of the nasal passages, 239 
Anosmia, 152 

diagnosis, 155 
etiology, 152 
pathology, 154 
prognosis, 154 
symptomatology, 153 
treatment, 156 
Anterior rhinoscopy, 8 
Antitoxin, results from the use of, 478 
in the treatment of diphtheria, 481 
Antrum of Highmore, 43 
disease of the, 250 
diagnosis, 255 
etiology, 250 

51 



Antrum of Highmore, disease of the, 
pathology, 253 
symptomatology, 254 
treatment. 257 
Aphonia, hysterical, 713 
Arteries of the larynx, 589 
Artery, crico-thyroid, 580 

dorsalis linguie, 376 

internal maxillary, 373 

laryngeal, inferior, 589 
posterior, 590 
superior, 579, 589 

lingual, 373 

palatine, ascending, 370, 373, 376 
descending, 370, 373, 376 

pharyngea suprema, 370 

pharyngeal, ascending, 370, 373 

tonsillar, 370, 373, 376 

Vidian, 370 
Articulate speech, 597 
Artificial larynx, 798 
Ary-epiglottic fold, 581, 582 
Arytenoideus, paralysis of the, 711 

treatment, 712 
Asthma, 133 

differential diagnosis, 133 

etiology, 133 

physical signs, 140 

prognosis, 140 

relation of, to hay fever, 134 

symptomatology, 139 

treatment, 141 
Atomizer, hand -ball, 21 
Atrophic rhinitis, 94 

Benign tumors of the fauces (see Tu- 
mors) . 544 
Bifid uvula, 374 

Blood-vessels of the nasal fossse, 46 
Bosworth's head -band and mirror, 6 
Bronchitis, vaso-motor, 133 



802 



INDEX. 



Bursa pharyngea, 282 

Carcinoma of the fauces, 561 
of the pharynx, 569 
of the larynx, 755 
of the nasal passages, 247 
of the nasopharynx, 331 
of the pharynx, 569 
diagnosis, 571 
etiology, 569 
pathology, 569 
prognosis, 570 
symptoms, 570 
treatment, 572 
of the soft palate, 561 
of the tonsil, 563 
diagnosis, 566 
etiology, 564 
pathology, 564 
prognosis, 567 
symptomatology, 564 
treatment, 568 
Cartilages, arytenoid, 577 
cricoid, 575 # 
inter-arytenoid, 579 
of larynx, 575 
nasal, 41 
of San tor in i, 578 
sesamoid, anterior, 579 

posterior, 579 
thyroid. 576 
of Wrisberg. 578 
Catarrh, use of the term, 54 
Catarrhal diseases, general considerations 
concerning, 54 
inflammation, chronic, 27 
secretion in, 55 
Cavity of the larynx, 580 
Chondroma of the larynx, diagnosis, 744 
pathology, 742 
treatment, 750 
of the nasal passages, 242 
of the naso-pharynx, 327 
Chorditis tuberosa, 635 
Chorea of the larynx, 722 

treatment, 725 
Cicatricial deformities in syphilis of 
fauces, 505 
treatment, 509 
stenosis of larynx, 673 
Cold, prevention of a, 36 



Cold, taking, 32 

treatment of a, 39 
Columnar cartilage, dislocation of, 170 
Congenital absence of tonsil, 377 

syphilis of nasal passages, 201 
Crico-thyroid membrane, 580 
Croup and diphtheria, duality between, 

467 
Croupous inflammation, 29 

rhinitis, 105 
Cusco's laryngeal forceps, 730 
Cushion of the epiglottis, 582 
Cystoma of the larynx, diagnosis, 744 
pathology, 741 
treatment, 749 

of the nasal passages, 238 

Deep syphilitic ulcer of the larynx, 671 
Deformities of the nasal septum, 157 
Deglutition, 378 

action of the muscles in, 378 
elevation of larynx and pharynx 
during, 379 
Delano's atomizer, 21 
Development of lung disorders from ca- 
tarrh of upper air passages, 35, 54 
Diphtheria, 467 
diagnosis, 475 

difference between croupous and 
diphtheritic inflammation, 476 
pseudo-diphtheria, 476 
duality between croup and diphthe- 
ria, 467 
etiology, 468 

methods of dissemination, 469 
predisposing causes, 468 
pathology, 470 

the bacillus, 470 
changes in the viscera, 471 
diphtheritic process in the 
fauces, 470 
prognosis, 476 

antitoxin, results of, 478 
mixed infections, 480 
sequelae, 489 
symptomatology, 471 
malignant form, 475 
mild form, 471 
typical form, 473 
treatment, 480 
antitoxin, 481 



INDEX. 



803 



Diphtheria, treatment, hygienic man- 
agement of the sick-room, 488 
internal medication, 485 
inhalations, 487 
intubation, 487-489 
sprays, 487 

topical applications, 483 
tracheotomy, 487-489 
Diphtheritic inflammation, 30 
Dislocation of the columnar cartilage, 

170 
Douches, nasal, 18 
Duality between croup and diphtheria, 

467 
Dysphagia spastica, 723 
treatment, 725 

Epiglottis, 578 
Epistaxis, 174 
etiology, 174 

diathetic, 174 
local lesions, 175 
traumatic, 174 
vicarious, 174 
diagnosis, 176 
pathology, 175 
symptomatology, 175 
treatment, 176 

applications to bleeding point, 

179 
infusion, 180 
local applications, 176 
plugging through anterior and 

posterior nares, 178 
position, 176 
pressure, 176 
Erythema of the fauces in syphilis, 498 

larynx in syphilis, 667 
Ethmoidal cells, posterior, 43 
sinuses, 43 
diseases of, 216 
Eustachian tube, 279-281 
Examination of the upper air passages, 

3, 6 
External nose, 41 

surgery of the throat, 763 
Extirpation of the larynx, 791 
after-treatment, 797 
artificial larynx, 798 
indications for, 791 
operation, 791 



Fauces, the, 367 

abnormalities of sensation in, 532 
anatomy, of, 367 

benign tumors of (see Tumors), 544 
carcinoma of (see Carcinoma), 561 
chorea of, 533 
diseases of, 367 
foreign bodies in, 529 
herpes of, 541 
lupus of, 521 
mycosis of, 457 
myopathic paralysis of, 534 
neuralgia of, 532 
neuroses of (see Neuroses), 532 
physiology of, 378 
pillars of, 371 
reflex neuroses of, 533 
sarcoma of (see Sarcoma), 551 
syphilis of (see Syphilis) , 496 
tuberculosis of (see Tuberculosis) . 
512 
Fibrinous rhinitis, 105 
Fibroma of the larynx, diagnosis of, 748 

pathology, 741 

treatment, 749 
of the nasal passages, 226 

diagnosis, 228 

etiology, 226 

pathology, 227 

prognosis, 229 

symptomatology, 227 

treatment, 229 
of the naso-pharynx. 316 
Foreign bodies in the air passages. 721) 

diagnosis, 728 

etiology, 726 

prognosis, 728 

symptomatology, 726 

treatment, 729 
in the fauces, 529 
in the nasal passages, 181 
Fossae, the nasal, 41 
Fracture of the larynx, 734 
diagnosis, 735 
etiology, 734 
prognosis, 735 
symptomatology, 734 
treatment, 735 
Frontal sinuses, the, 43 

diseases of, 271 
Function of the nose in phonation, 49 



804 



INDEX. 



Fnnction of the nose in respiration, 49 

Ganglionic cells presiding over the 

motor innervation of the larynx, 598 
Globe inhaler for inhaling fluids atom- 
ized by means of compressed air, 23 
Glottis, the, 583 
spasm of, 714 

in adults, 719 
in children, 715 
Gross' tracheal forceps, 732 
Gummy tumor of the fauces, 502 
larynx, 670 

Hand-ball atomizers, 21 
Hay fever, 115 

course and duration, 122 
definition, 115 
diagnosis, 124 
etiology, 116 

age, 118 

Blackley's experiments, 116 

diathetic conditions, 119 

heredity, 119 

morbid conditions of mucous 
membranes, 117 

neurotic habit, 117 

presence of pollen in the atmos- 
phere, 116 

sex, 118 
geographical distribution of, 124 
history, 115 
pathology, 119 
prognosis, 125 
relation of, to perennial asthma, 

134 
symptomatology, 120 

asthma, 121 

formication in the nose and 
throat, 120 

nasal stenosis, 121 

watery nasal discharge, 121 
treatment, 126 

bougies, 131 

cocaine, 130 

constitutional treatment, 126 

diseased condition of upper air 
passages, 128 

exacerbation, 130 

snuffs, 131 

sprays, 131 



Hearing, impairment of, due to hyper- 
trophy of tonsils, 433 
Hemorrhage, laryngeal, 664 

after tonsillotomy, 442 
Highmore, antrum of, 43 
Hyperesthesia of the larynx, 695 
Hypertrophic rhinitis, 68 
Hypertrophy of the lingual tonsil, 462 

diagnosis, 464 

etiology, 462 

pathology, 462 

prognosis, 465 

symptomatology, 463 

treatment, 465 
of the pharyngeal tonsil, 299 
of the tonsils, 430 

diagnosis, 434 

etiology, 430 

impairment of hearing, due to, 
433 

pathology, 431 

prognosis, 435 

symptomatology, 433 

treatment, 436 
Hysterical aphonia, 713 

Inflammation, acute catarrhal, 27 

chronic catarrhal, 28 

croupous, 29 

diphtheritic, 30 

of mucous membranes, 26 
Inhalations, 22 

value of, 24 
Inhalator, Mackenzie's, 22 
Inhaler, large Globe, for fluids atomized 

by compressed air, 23 
Insufflation, 17 
Insufflators. 17 
Intensity of the voice, 596 
Internal tensors of larynx, paralysis of 

the, 710 
Intubation in diphtheria, 487, 489 

Klebs-Loeffler bacillus, 450, 467, 468, 
481 

Laryngeal hemorrhage, 664 

course and prognosis, 666 
diagnosis, 665 
etiology, 664 
pathology, 665 



INDEX. 



805 



Laryngeal hemorrhage, symptomatol- 
ogy, 665 

treatment, 666 
image, 604 
mirror, 4 

ventricles, prolapse of the, 737 
vertigo, 722 

treatment, 725 
Laryngitis, acute, 608 

course and prognosis, 611 

diagnosis, 610 

etiology, 608 

pathology, 609 

symptomatology, 609 

treatment, 611 
acute in children, 614 
acute phlegmonous, 642 

diagnosis, 644 

etiology, 642 

pathology, 643 

symptomatology, 643 

treatment, 644 
chronic, 624 

catarrhal, 624 

diagnosis, 628 
etiology, 625 
pathology, 626 
prognosis, 629 
symptomatology, 627 
treatment, 630 
croupous, 650 

diagnosis, 652 

etiology, 650 

pathology, 651 

prognosis, 653 

symptomatology, 651 

treatment, 653 
cedematous (see Acute Phlegmonous 

Laryngitis), 612 
sicca, 638 

course and prognosis, 640 

diagnosis, 639 

etiology, 638 

pathology, 638 

treatment, 640 
subglottic, acute, in children, 616 

diagnosis, 619 

etiology, 616 

pathology, 617 

prognosis, 620 

symptoms, 617 



Laryngitis, subglottic, acute, in chil- 
dren, treatment, 620 

subglottic, chronic, 632 
diagnosis, 634 
etiology, 632 
pathology, 633 
prognosis, 634 
symptomatology, 633 
treatment, 635 

supraglottic, acute, in children, 614 
Laryngoscope, the, 4 
Laryngoscopy apparatus, fixed, 6 
Laryngoscopy, 600 
Laryngotracheal ozsena, 639 
Larynx, anaesthesia of, 695 

anatomy of, 575 

arteries of, 589 

benign tumors of (see Tumors), 738 

carcinoma of, 755 

cartilages of, 575 

cavity of, 580 

diseases of, 575 

extirpation of, 791 

fracture of (see Fracture) , 734 

ganglionic cells presiding over motor 
innervation of, 598 

hyperesthesia of, 695 

ligaments of, 579 

lupus of, 693 

lymphatics of, 590 

muciparous glands of. 588 

mucous membrane of. 588 

muscles of, 583 

nerves of, 591 

neuralgia of, 696 

neuroses of (see Neuroses), 695 

oedema of (see (Edema) , 646 

paresthesia of, 696 

in phonation, function of, 595 

physiology of, 594 

resection of, 799 

in respiration, function of, 594 

sarcoma of, 752 

subglottic portion of, 581 

supraglottic portion of, 581 

syphilis of (see Syphilis), 667 

trachoma of, 635 

tuberculosis of (see Tuberculosis). 
680 

veins of, 590 
Layers of the mucous membranes, 26 



SOG 



INDEX. 



Leptothrix, the, 458 
Levator palati, the, 280 
Ligament, cricoarytenoid, posterior, 580 
glosso-epiglottic, 579 
lateral, 579 
median, 580 
liyo-epiglottic, 580 
internal or intrinsic, of the larynx, 

580 
of larynx, 579 
thyro-epi glottic, 580 
thyro-hyoid, lateral, 579 
Light condenser, Mackenzie's, 6 

sources of, for purposes of examina- 
tion, 6 
Lingual tonsil, Hypertrophy of (see Hy- 
pertrophy), 462 
Lipomata of the larynx, pathology of, 

743 
Loewenberg's ozsena diplococcus, 638 
Lung disorders, development of, from 

catarrh, 35 
Lupus of the fauces, 521 
diagnosis, 524 
etiology, 521 
pathology, 522 

relationship between lupus and tu- 
berculosis, 528 
symptomatology, 524 
treatment, 526 
curette, 527 
excision, 527 
internal medication, 527 
topical applications, 526 
tuberculin, 528 
of the larynx, 693 
of the nasal passages, 208 

course and prognosis, 210 
diagnosis, 209 
etiology, 208 
pathology, 209 
symptomatology, 208 
treatment, 210 
Luschka's tonsil, 281 
Lymphatics of the larynx, 590 

Mackenzie's inhalator, 22 

light condenser, 6 
Meatus, inferior, 42 

middle, 42 

superior, 42 



Methods of treating upper air passages 

by means of instruments, 17 
Middle ear, inflammation of, in acute 

rhinitis, 66 
Minor's laryngeal retractor, 732 
Moisture in inspired and expired air, 50 
Motor innervation of the larynx, gan- 
glionic cells presiding over the, 598 
Mouth breathing, results of, 433 
Muciparous glands of the larynx, 588 
Mucous membranes, 25 
histology of, 25 
inflammation of, 26 
layers of, 25 
of the larynx, 588 
of the nasal cavities, 44 
physiology of, 26 
patch in the larynx, 669 

in syphilis of the fauces, 499 
Muscles, ary -epiglottic, 586 
arytenoid, 586 
azygos-uvula;, 372 
crico - arytenoid, lateral, 575, 580, 
585 
posterior, 576, 585 
crico -thyroid, 577, 580, 583 
inferior constrictor of larynx, 577 
kerato- cricoid, 585 
of larynx, 583 
laryngopharyngeal, 587 
levator palati, 372 
longus colli, 369 
palato-glossus, 372 
palato-pharyngeus, 373 
petro-salpingo-staphylinus, 372 
of pharynx, inferior constrictor, 369 
middle constrictor, 368 
superior constrictor, 368 
rectus capitis anticus major, 369 
sterno-hyoid, 587 
sterno-thyroid, 577 
stylo-pharyngeus, 369, 577 
tensor palati, 280, 372 
thyro-arytenoid, 577, 580, 582, 586 
superior, 586 
thyro-epiglottic, 586 
thyro-hyoid, 577, 587 
Mycosis of the fauces, 457 
Myxofibroma of the naso-pharynx, 323 
Myxoma of nose, 216 
anosmia, 219 






INDEX. 



807 



Myxoma of nose, attachment, 216 

aural symptoms, 220 

diagnosis, 220 

disease of the antrum, 219 

etiology, 217, 218 

operation, 223 

pathology, 216 

prognosis, 221 

reflex disturbance, 219 

sneezing and stenosis, 219 

symptomatology, 218 

treatment, 221 
Myxomata of the larynx, diagnosis. 
741 

pathology, 745 

treatment, 750 

Nasal cartilages, 41 
Nasal cavities, innervation of mucous 
membrane of, 45 

mucous membrane of, 44 

parasites in, 186 

vascular supply of, 46 

douches, 18 

fossa?, 41 

hydrorrhea, 145 
etiology, 148 
prognosis, 150 
symptomatology, 150 
treatment, 151 
Nasal passages, 41 

adenoma of, 237 

angioma of, 239 

carcinoma of, 247 

chondroma of, 242 

congenital syphilis of, 201 

cystoma of, 238 

diseases of, 3 

fibroma of (see Fibroma) , 226 

foreign bodies in, 181 

lupus of (see Lupus), 208 

osteoma of (see Osteoma) , 231 

papilloma of (see Papilloma), 234 

sarcoma of, 243 

syphilis of (see Syphilis), 188 

tuberculosis of (see Tuberculosis), 
204 
Nasal polypus (see Myxoma) , 216 
Nasal reflexes, 109 
Nasal septum, abscess of, 172 
Nasal septum, deformities of, 157 



Nasal septum, deformities of, abnormal- 
ities of facial development, 159 
abnormality of palate, 159 
classification, 158 
congenital, 159 
diagnosis, 162 
etiology, 159 

excessive development of vomer, 160 
prognosis, 163 
rachitis, 160 
symptomatology, 161 
deformity, 161 
epistaxis, 162 
laryngeal symptoms, 162 
stenosis, 161 
syphilis, 160 
traumatism, 159 
treatment, 164 

operation by means of a punch, 

164 
removal of deformity by means 
of forceps or dental engine, 
165 
removal by means of the saw, 
167 
Nasal specula, 8 
Naso-pharyngeal catarrh, 288 
diagnosis, 293 
etiology, 288 
prognosis, 294 
symptomatology, 291 
treatment, 294 
Naso-pharyngitis, acute, 284 
diagnosis, 285 
etiology, 284 
prognosis, 286 
symptomatology, 284 
treatment, 286 
Naso-pharynx, anatomy and physiology 
of, 279 
arterial supply of, 281 
carcinoma of, 331 
chondroma of, 327 
diseases of, 279 
fibroma of, 316 
myxo-fibroma of, 323 
nerve supply of, 281 
sarcoma of, 328 
structure of -walls of, 281 
Nerve supply of nasal mucous mem- 
brane, 45 



808 



INDEX. 



Nerves, facial, 374 
fifth, 374, 377 

glosso- pharyngeal, 370, 374, 377 
of larynx, 591 

laryngeal, inferior or recurrent, 591 
median, 592 
superior, 579, 591 
vagus, 374 
Neuralgia of the larynx, 696 
Neuroses of the fauces, 532 

abnormalities of sensation, 532 
bulbar lesion, paralysis due to, 536 
bulbar paralysis, or myelitis, acute, 
536 
chronic, 537 

due to presence of tumors, 
meningitis, etc., 540 
herpes of the fauces, 541 
myopathic paralysis, 534 
neuralgia, 532 
reflex neuroses, 533 
spasmodic disturbance or chorea, 

533 
sudden or apoplectic bulbar paraly- 
sis, 538 
Neuroses of the larynx, 695 
anaesthesia, 695 
aphonia, hysterical, 713 
arytenoideus, paralysis of the, 711 
bilateral abductor paralysis, 702 
diagnosis, 706 
etiology, 703 
pathology, 705 
prognosis, 706 
symptomatology, 705 
treatment, 707 
bilateral adductor paralysis, 710 
glottis, spasm of, 714 
in adults, 718 
in children, 715 
hyperesthesia, 695 
individual muscles, paralysis of, 

709 
internal tensors, paralysis of, 710 
laryngeal inco-ordination, 722 
chorea of larynx, 722 

treatment, 725 
dysphonia spastica, 723 

treatment, 725 

laryngeal vertigo. 723 

treatment, 725 



Neuroses of the larynx, neuralgia, 696 
paresthesia, 696 

paralysis of recurrent laryngeal 
nerves, 696 
etiology, 698 
pathology, 699 
symptomatology, 699 
treatment, 702 
of superior laryngeal nerve, 696 
treatment, 724 

unilateral paralysis of abductors, 
708 
of adductors, 709 
Nose, anatomy of, 41 
external, 41 

external surgery of, 335 
function of, in phonation, 49 

in respiration, 49 
physiology of, 48 

O'Dwyer's instruments for intubation, 

491 
(Edema of the larynx, 646 
• diagnosis, 647 

etiology, 646 

pathology, 647 

prognosis, 648 

symptomatology, 647 

treatment, 648 
Oro- pharynx, the, 367 

fibrous layer of, 368 

mucous membrane of, 368 

muscular layer of, 368 

tumors of, 550 
Osteoma of the nasal passages, 231 

diagnosis, 232 

etiology, 231 

pathology, 232 

prognosis, 233 

symptomatology, 231 

treatment, 233 
Ozena, laryngotracheal, 639 

Palate, arterial supply of the, 373 

retractor, self -retaining, 14 
Palato-pharyngeus, the, 280 
Papillomata of the larynx, diagnosis, 
743 
pathology, 740 
treatment, 749 
of nasal passages, 234 



INDEX. 



809 



Papillomata of nasal passages, diagnosis, 
235 
etiology, 234 
pathology, 234 
prognosis, 236 
symptomatology, 234 
treatment, 236 
Paresthesia of the larynx, 696 
Paralysis, bilateral, of abductor muscles 
of larynx, 702 
diagnosis, 706 
etiology, 703 
pathology, 705 
proguosis, 706 
symptomatology, 705 
treatment, 707 
of adductor muscles of larynx, 710 
Paralysis of fauces, due to bulbar le- 
sions, 536 
Parasites in the nasal cavities, 186 
Perichondritis of laryngeal cartilages, 
656 
diagnosis, 659 
etiology, 656 
pathology, 656 
prognosis, 661 
symptoms, 657 
arytenoid, 658 
cricoid, 657 
epiglottis, 659 
thyroid, 658 
treatment, 662 
Peritonsillar abscess, 418 
Perforation of the septum, 171 
Pharyngeal plexus, the, 370 
Pharyngeal tonsil, the, 281 
hypertrophy of, 299 
diagnosis, 305 
etiology, 299 
pathology, 300 
prognosis, 307 
sequelae, 315 
symptomatology, 301 
treatment, 307 
Pharyngitis, acute, 381 
diagnosis, 384 
etiology, 381 
age, 382 
disturbances of digestive tract, 

382 
drugs, 383 



Pharyngitis, acute, etiology, exposure 
to cold, 381 

irritants, 382 
pathology, 383 
prognosis, 385 

cedema of glottis, occurrence of. 
385 

paralysis of palate as a sequel, 
385 
symptomatology, 383 
treatment, 385 

cocaine, 386 

gargles, 385 

internal medication, 386 

lozenges, 385 

opiates, 386 

scarification, 387 
Pharyngitis, chronic, 388 
diagnosis, 389 
etiology, 388 

gastritis, 388 

hypertrophic rhinitis, 389 

naso-pharyngeal disease, 389 

tobacco, 388 
pathology, 389 
symptomatology, 389 
treatment, 390 
Pharyngitis, chronic follicular, 391 
diagnosis, 396 
etiology, 391 

age, 391 

impairment of health, 392 

improper nutrition, 392 

lymphatic diathesis, 392 

rheumatic and gouty diathesis, 
392 
pathology, 392 
prognosis, 396 
symptomatology, cough, 396 

hoarseness, 395 

hypersecretion, 394 

pain, 394 
treatment, 397 

avoidance of alcohol or tobacco, 
397 

galvano-cautery, 397 

general tonics, 397 
Pharyngotomy, 763 
lateral, 765 

Bergmann's method, 767 

Cheever's method, 76!) 



810 



INDEX. 



Pharyngotomy, lateral, Kuster's method, 
767 
Langenbeck's method, 765 
Mikulicz' method, 768 
Polaillon's method, 770 
sub-hyoid, 763 
Pharynx, acute infectious phlegmon of, 
399 
diagnosis, 402 
etiology, 399 
age, 399 

blood poisoning, 399 
traumatism, 399 
pathology, 399 
prognosis, 402 
symptoms, 400 
treatment, 403 
Pharynx, arterial supply of, 370 

carcinoma of (see Carcinoma), 509 
lymphatics of, 371 
measurements of the upper, 281 
nerve supply of, 370 
sarcoma of, 557 
veins of, 371 
Phonation, action of muscles of larynx 
in, 595 
function of the larynx in, 595 
function of the nose in, 49 
Physiology of the larynx, 594 
of the mucous membranes, 26 
of the naso-pharynx, 283 
of the nose, 48 
Pillars of the fauces, 371 
Pitch of the voice, 596 
Plica-salpingo-pharyngeal, the, 280, 370 
Polypus, nasal (see Myxoma), 216 
Posterior rhinoscopy, 12 
Post -nasal syringe, 18 
Primary lesion of syphilis of fauces, 496 

of syphilis of larynx, 667 
Prolapse of the laryngeal ventricles, 737 
Pseudo-diphtheria, 476 
Purulent rhinitis of children, 89 

Quality of the voice, 596 

Quinsy, 418 

course and prognosis, 424 
chronic abscess as a sequela of, 425 
destructive process in, 425 
result of delayed evacuation, 424 
suffocation, 425 



Quinsy, definition, 418 
diagnosis, 422 

differential diagnosis from an- 
eurism, 423 
etiology, 418 

age, 418 

enlarged tonsils, 419 

heredity, 419 

occupation, 419 

rheumatic habit, 419 

season, 418 

sex, 418 
pathology, 419 
symptomatology, 420 
treatment, 425 

abortive measures, 425 

aconite, 426 

anti -rheumatic remedies, 426 

surgical measures, 427 

Recessus ethmoidals, 43 
Recurrent laryngeal paralysis, 698 

etiology, 698 

pathology, 699 

symptomatology, 699 

treatment, 702 
Reflecting mirror, 5 
Reflexes, nasal. 109 

local treatment in, 114 
Resection of the larynx, 799 

after-treatment, 800 

operation, 799 
Respiration, function of larynx in. 594 

function of nose in, 49 
Retro-pharyngeal abscess, 404 

course and prognosis, 408 

diagnosis, 407 

etiology, 404 
age, 404 

exanthemata, 405 
idiopathic, 404 
sex, 404 

pathology, 405 

symptomatology, 406 
in adults, 406 
in children, 406 

treatment, 409 
Rhinitis, acute, 59 

diagnosis, 60 

etiology, 59 

inflammation of middle ear in, 66 



INDEX. 



811 



Rhinitis, acute, involvement of the ac- 
cessory sinuses in, 66 
prognosis, 61 
prophylaxis, 61 
symptomatology, 60 
treatment, 62 

aconitine. 66 

astringents. 63 

baths, 62 

camphor, 65 

chromic acid, 65 

cocaine. 61 

Davis' powders. 62 

heat. 66 

inhalations, 63 

opium, 63 

quinine, 6'2 
Rhinitis, atrophic. 95 
diagnosis, 100 
etiology, 96 
symptomatology. 98 
treatment. 101 

douche. 101. 103 

galvanism. 103 

galvano-cautery, 102 

iodol, 102 

snuffs, 103 

sprays, 103 

tampons, 102 
Rhinitis, croupous or fibrinous, 105 
diagnosis, 106 
etiology, 105 
pathology. 106 
prognosis, 107 
symptomatology. 106 
treatment, general, 107 

local. 107 
Rhinitis, hypertrophic, 68 
diagnosis, 76 
etiology, 68 
pathology, 75 
symptomatology, 71 
treatment, 79 

caustics, 81 

galvano-cautery, 83 

injections, 79 

powders, 80 

snare, 85 

sprays, 79 
Rhinitis, purulent, of children, 89 
diagnosis, 91 



Rhinitis, purulent, of children, etiology, 
91 

symptomatology, 91 

treatment, 93 
Rhinitis, vasomotor, 115 
Rhinoliths, 184 

diagnosis, 184 

etiology, 184 

symptomatology, 184 

treatment, 185 
Rhino-scleroma, 212 

diagnosis, 214 

etiology, 212 

pathology, 213 

prognosis, 215 

symptomatology, 212 

treatment, 216 
Rhinoscopic image, the, 15 
Rhinoscopy, 8 

anterior, 8 

posterior, 12 
Rima glottidis, 581, 583 
Rosenmiiller, the fossa of, 280, :>70 

Sacculus laryngis, 582 
Salpingeal pharyngeal fold, the, 370 
Santoriui, cartilages of, 578 
Sarcoma of the fauces, 551 
of pharynx, 557 
diagnosis, 558 
etiology, 557 
pathology, 557 
prognosis, 558 
symptomatology, 558 
treatment, 559 
of soft palate and pillars of fauces, 

551 
of tonsil, 553 

diagnosis, 555 
etiology, 553 
prognosis, 555 
symptomatology, 554 
treatment, 556 
Sarcoma of the larynx, 752 
of the nasal passages, 243 
of the naso-pharynx, 328 
Sass' tubes, 20 
Secretion in catarrhal inflammation, 55 

character of, 57 
Seller's tube forceps, 733 
Septum, abscess of, 172 



812 



INDEX. 



Sinuses, the accessory, 43 
diseases of, 250 

ethmoidal, 43 

diseases of, 216 

frontal, 43 

diseases of, 271 

sphenoidal, 43 

diseases of, 267 
Singing voice, the, 598 
Smell, sense of, 48 
Snuffs, 17 
Soft palate, 371 

anomalies of, 374 

arteries of, 373 

carcinoma of, 561 

lymphatics of, 373 

motor nerves of, 373 

mucous membrane of, 371 

muscles of, 372 

sarcoma of, 551 

sensory nerves of, 374 

tumors of, 544 

veins of, 373 
Specula, nasal, 8 
Sphenoidal sinus, 43 

diseases of, 267 
Spray tubes, 20 
Stenosis, cicatricial, of thelarnyx, 674 

treatment, 676 
Superficial laryngeal nerve, paralysis of, 
696 

syphilitic ulcer of larynx, 669 
Surgery, external, of the nose, 335 

Annandale's operation, 354 

Berard's operation, 361 

Billroth 's operation for temporary 
resection of superior maxilla, 356 

Boeckel's operation, 341, 357 

Botrel's operation, 337 

Bruns' operation, 346 

Cheever's operation, 349 
double operation, 351 

Demar quay's operation, 357 

Dezeanneau's operation, 338 

Dieffenbach's operation, 338 

Fouraux-Jordan's operation, 348 

Huguier's operation, 348, 362 

Langenbach's operation for resec- 
tion of nasal bone, 344 
for temporary resection of su- 
perior maxilla, 354 



Surgery, external of the nose, Lariche's 
operation, 339 
Lawrence's operation, 343 
Linhart's operation, 346 
Manne's operation, 335 
Maisonneuve's operation, 336 
Nelaton's operation, 336 
Ollier's operation, 342 
Palasciano's operation, 340 
Pean's operation, 360 
Rouge's operation, 340 
Roux's operation, 352 
Richard's operation, 337 
Sedillot's operation, 337 
Vallet's operation, 362 
Waterman's operation, 352 
Surgery, external, of throat, 763 
Syphilis, congenital, of the nasal pas- 
sages, 201 
diagnosis, 202 
early manifestations, 201 
prognosis, 203 
treatment, 204 
Syphilis of the fauces, 496 

cicatricial deformities of fauces, 

505 
deep ulcer of syphilis, 503 
erythema of fauces, 498 
gummy tumor, 502 
mucous patch, 499 
primary lesion, 496 
superficial ulcer, 501 
treatment, 508 
Syphilis of the larynx, 667 
cicatricial stenosis, 673 
deep ulcer, 671 
erythema of larynx, 667 

course and prognosis, 668 

diagnosis, 668 

pathology, 667 
gummy tumor, 670 
mucous patch, 669 
primary lesion, 667 
superficial ulcer, 669 
treatment, 676 

of cicatricial stenosis, 676 

deep ulcer, 676 

erythema, 676 

mucous patch, 676 

primary ulcer, 676 

superficial ulcer, 676 






INDEX. 



813 



Syphilis of tbe nasal passages, 188 
coryza, 189 
erythema, 189 
deep ulcer and bony necrosis, the, 193 

course and duration, 196 

diagnosis, 195 

symptomatology, 194 
gummy tumor, the, 190 

course and duration, 192 

diagnosis, 191 

pathology, 192 

symptomatology, 191 
mucous patch, the, 189 
primary lesion, the, 188 

diagnosis of, 188 
superficial ulcer, the, 189 
treatment, 197 

constitutional, 200 

coryza, or erythema, 197 

deep ulcer, 199 

general, 200 

gummy tumor, 198 

mucous patch, 197 

primary lesion, 197 

superficial ulcer, 197 
Syringe, post-nasal, 18 

Taking cold, 32 

causes of, 33 

theories of, 32 
Third tonsil, the, 281 
Throat, external surgery of, 763 

mirror, the, 4 
Thyrohyoid membrane, 579 
Thyrotomy, 771 

indications for, 771 

operation, 771 
Tobacco, influence of, in catarrhal dis- 
eases, 69 
Tobold's laryngoscopy apparatus, 6 
Tongue depressors, 12 
Tonsil liths. 454 
Tonsillitis, acute follicular, 446 

diagnosis, 450 

etiology, 446 

pathology, 448 

prognosis, 450 

symptomatology, 449 

treatment, 452 
Tonsillitis, croupous (see Acute Follic- 
ular Tonsillitis), 446 



Tonsillotomes, 438 
Tonsillotomy, 437 

hemorrhage after, 442 
Tonsil, hypertrophy of the lingual (see 

Hypertropny) , 462 
Tonsils, anatomy of the, 375 

anatomical relations of, 375 

anomalies of, 377 

arteries of, 376 

carcinoma of, 563 

congenital absence of, 377 

function of, 379 

hypertrophy of, 430 
due to rachitis, 434 

lymphatics of, 377 

mucous membrane of, 376 

nerves of, 377 

pedunculated growths from, 377 

sarcoma of. 553 

tumors of, 549 

veins of, 377 
Tracheotomy, 775 

after-treatment, 789 

anaesthetics in, 778 

arterial anomalies in, 781 

in diphtheria, 487, 489 

indications for. 778 

instruments, 778 

operation, 783 

crico-thyroid laryngotomy, 788 
infra- thyroid tracheotomy, 784 
laryngo-tracheotomy, 788 
median tracheotomy, 788 
rapid tracheotomy, 789 
supra-thyroid tracheotomy, 787 

regional anatomy of the parts in, 779 

removal of the tubes, 700 

selection of operation, 781 

tubes, 775 
Trachoma of the larynx, 635 
Tuberculosis of the fauces, 512 

course and prognosis, 515 

diagnosis, 515 

etiology, 512 

pathology, 514 

symptomatology, 514 

treatment, 516 
Tuberculosis of the larynx, 680 

diagnosis, 683 

etiology, 680 

prognosis. 687 



814 



INDEX. 



Tuberculosis of the larynx, symptom- 
atology, 682 
treatment, 688 
Tuberculosis of the nasal passages, 205 
diagnosis, 206 
etiology, 205 
pathology, 205 
prognosis, 207 
symptomatology, 206 
treatment, 207 
Tubes, spray, 20 

Tumors, benign, of the fauces, 544 
of oro-pharynx, 550 
of soft palate, uvula, and pillars of 
fauces, 544 

adenoma, 546 

angioma, 545 

calcareous degeneration, or pala- 
toliths, 548 

dermoid tumors, 547 

fibroma, 545 

papilloma, 544 
of tonsil, 549 

fibroma, 549 
Tumors, benign, of the larynx, 738 
diagnosis, 743 

angiomata, 745 

chondromata, 744 

cystomata, 744 

fibromata, 743 

myxomata, 745 

papillomata, 743 
etiology, 738 
pathology, 740 

adenomata, 743 

angiomata, 742 

chondromata, 742 

cystomata, 742 

fibromata, 741 

lipomata, 743 

myxomata, 741 

papillomata, 740 
symptomatology, 739 
treatment, 746 

angiomata, 750 

chondromata, 750 

cystomata, 749 

fibromata, 749 



Tumors, benign, of the larynx, myxo- 
mata, 750 
papillomata, 749 
Turbinated bodies, the, 46 
bone, inferior, 42 
middle, 42 
superior, 42 

Ulcer, deep, in syphilis of fauces, 501 

superficial, in syphilis of fauces, 503 
Unilateral abductor paralysis in larynx, 
708 
adductor paralysis, 709 
Upper air passages, methods of examin- 
ing, 3 
Uvula, the, 371 
bifid, 374 
elongated, 414 
diagnosis, 415 
etiology, 414 
pathology, 414 
prognosis, 415 
symptomatology, 414 
treatment, 415 
hemorrhage after removal of, 417 
removal of, 415 • 
tumors of, 544 
Uvulitis, acute, 411 
diagnosis, 412 
etiology, 411 
pathology, 412 
prognosis, 412 
treatment, 412 
Uvulitis, chronic, 412 
Uvulotomy, hemorrhage after, 417 

Vasomotor bronchitis, 133 

rhinitis, 115 
Veins of the larynx, 590 

of the pharnyx, 371 
Velum pendulum palati, 371 
Ventricles of the larynx, 582 
Ventricular bands of the larynx, 582 
Vocal cords, false, 582 

true, 582 
Voice, formation of the whispering, 597 

pitch, intensity and quality of, 596 




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